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... 1 Empowering Brighter Futures: An Occupational Approach to Gaining Life Skills Stephanie McElhaney May, 2022 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Christine Kroll, OTD, MS, OTR, FAOTA 2 Abstract This study examined the efficacy of an occupation-based program in a substance use disorder recovery facility for women. A literature review of previous studies found that occupational therapy practitioners have the skills and abilities to help those with substance use disorder enhance their occupational and functional performance. In addition, studies have found that boredom is a risk factor for relapse. This study utilized the Modified Interest Checklist to assess the needs of the clients at the recovery facility. The results of the assessment aided in the development of a program that focused on gaining new occupations and skills. The results of this study determined the need for further occupation-based programming and continuing research on the efficacy of occupational therapy services for those with substance use disorder. Keywords: Substance use disorder, occupational therapy, occupation-based program 3 Empowering Brighter Futures: An Occupational Approach to Gaining Life Skills The Dove Recovery House for Women is a Level IV recovery facility for women in Marion County struggling with substance use disorder (SUD) and who want to complete the treatment process. Each year, more than 80 women above 18 years of age enter the program at this facility, and approximately 70.5% of women successfully complete treatment. There is a 90day commitment, but individuals can reside at the facility for up to two years (C. Duggar, personal communication, January 14, 2022). Thanks to grants, donors, and sponsors from the community, the facility is free to individuals. Overall, the mission of Dove Recovery House is to empower women to become substance-free, self-sufficient, and healthy, by providing safe housing, quality programming, and above all - hope for the future (Home, n.d.). Substance use disorder (SUD) is a condition in which there is uncontrolled use of substances despite harmful consequences (American Psychological Association, 2021). According to the Substance Abuse and Mental Health Service Administration (SAMHSA), in 2019, 20.3 million people above the age of 12 years were living with SUD (SAMHSA, n.d.), including addictions to opiates, stimulants, depressants, psychedelics, and marijuana (MedlinePlus, 2019). In 2019 alone, approximately 70,630 individuals died from an opioidrelated drug overdose (ASPA, 2019). As the rates of SUD increase, there is an increased need for prevention and treatment programs across the nation. Studies show that individuals in recovery from SUD may improve their well-being by engaging in positive activities and activities that teach them about themselves or others (Hoxmark et al., 2011; Peloquin et al., 2017). In addition, individuals have a higher chance of relapsing if they suffer from boredom (Corvinelli, 2005). Therefore, a program that focuses on engaging individuals in meaningful activities to replace the 4 occupation of addiction would benefit the clients at Dove Recovery House for Women and may prevent relapse. Background Recovery from substance use disorder is a tedious process in which individuals abstain from substance use and attempt to improve their health and well-being. The recovery process may include participation in inpatient addiction treatment facilities, outpatient addiction treatment facilities, intensive outpatient programs, partial hospitalization programs, mutual support groups, otherwise known as 12-step programs, detoxification, co-occurring disorder treatment, and behavior therapy (Brande, 2022). A team of skilled medical professionals is often in charge of determining the appropriate treatment for the client based on their current needs. Unfortunately, it is common for individuals to relapse while in recovery, making overdosing more likely (People who use drugs are real people, 2014). Even though the treatment options for those with substance use disorder are plentiful, more than 101,623 people died from overdoses last year, and studies find that only 9% of all substance abusers eventually recover (Mann, 2022). As substance use disorder continues to be a challenge for individuals, the need for programs to replace the occupation of addiction is present, specifically programs related to life after substance abuse in the form of meaningful or vital activities. A 2011 study found that individuals with substance use disorder reported a significant drop in activity participation during the abuse of substances but reported a strong desire to increase participation in activities during recovery (Hoxmark et al., 2011). This same study found that losing participation in meaningful 5 activities may also lead to an overall decrease in well-being (Hoxmark et al., 2011). Therefore, participation in positive activities may increase well-being and aid in addiction recovery. Replacing the occupation of addiction is crucial in recovery. A study conducted in 2019 found that boredom often leads to a negative impact on mental health and a resurgence in substance abuse. The researchers found that engagement in new meaningful activities positively impacted the clients and their mental well-being (Marshall et al., 2019). Other studies show that women in recovery revealed high satisfaction after engaging in self-development and life skill groups (Peloquin et al., 2017). It also has been found that occupational therapy, as a profession, has the skills and abilities to enhance the functional independence and occupation performance of a client in substance abuse recovery (Amorelli, 2016). An interview with Celli Dugger, the former operations director at Dove Recovery House, in March of 2021 demonstrated a need for programs related to self-sufficiency and living a substance-free life. Ms. Dugger reported that the facility already offers courses related to parenting, life skills coaching, financial management, relapse prevention, and domestic violence services. Still, she would like to see more programs related to meaningful occupations, home management, and vocational skills. She also mentioned the need for a program that assists the clients in gaining access to transportation, as many of the individuals do not drive or own a vehicle (C. Duggar, personal communication, March 3, 2021). In a recent interview with Ms. Dugger in January of 2022, she indicated a continuing need for occupation-based programs and emotional regulation. She also stated there is a need for occupational therapy services at Dove Recovery House and believes the clients would benefit from occupational interventions (C. Duggar, personal communication, January 10, 2022). 6 In addition to multiple interviews with Ms. Dugger, I interview Lara Chandler, the current chief operations officer, and assessed the clients' needs at Dove Recovery House using the Modified Interest Checklist to determine what activities the clients found meaningful and were interested in participating. The Modified Interest Checklist gathers information on the clients past, current, and future interests in engaging in 68 different occupations. The checklist results determined that the clients were most interested in activities related to health and wellness, such as walking and dancing; home management, such as cleaning, laundry, and cooking; and leisure, such as puzzles and crafts. Although multiple studies related to engaging individuals with a history of substance use disorder in meaningful activities, there is very little research about occupation-based programs, even though occupational therapists are skilled in creating interventions for this population. One study found that most occupational therapy practitioners did not assess substance use disorders, or treat them (Thompson, 2007). There has also been limited evidence on treating clients with a holistic approach. Much of the literature focuses on specific aspects of the client, such as their participation in sleep, work, or being a mother, but not necessarily on all the client's aspects. The research and project I am completing at Dove Recovery House aim to holistically look at the clients wants and needs. I recognize that there is more to a client than their history of addiction and participation in one occupation. As the needs assessment indicated, many clients have multiple interests and are not only concerned with participation in a singular activity. My project is focused on engaging clients in meaningful occupations and discovering new ones, improving overall occupational performance, and reducing the risk factors that contribute to substance use relapse. 7 Theory and Frame of Reference I chose the KAWA model as a guiding theory for my doctoral capstone experience. This model focuses on the interaction between the person, environment, and circumstances surrounding their lives (About, 2016). The model is represented by a river, and its flow is a metaphor for life. Along the path, rivers may run into obstacles such as rocks and bends, and the flow of the river changes, much like life. I chose this model because many of the clients I have worked with have had some obstacle that has interfered with their flow, making it difficult to succeed. A study conducted in 2017 demonstrated the use of the KAWA for teambuilding, creating a cohesive environment, and addressing issues among group members. The study demonstrated a positive use of the theory and found it effective in group settings (Lape & Scaife, 2017). I have chosen the Lifespan Development framework as a guiding frame of reference. I primarily focused on the work of Daniel Levinson and his theory regarding the areas of adult life (Cole & Tufano, 2008). The Lifespan Development framework can be related to individuals experiencing substance use disorders, as this framework primarily focuses on the multidimensional and socio-cultural influences individuals experience throughout life. A study conducted in 2020, found that events throughout the lifespan and changes in life influence substance use. For example, recreational drug use was more common among teenagers due to peer pressure and societal norms (Shepis et al., 2020). Another study conducted in 2019 also investigated substance use across the lifespan and found it to be an indicator of future unemployment and poor mental health. This study highlighted the importance of programs around substance use prevention, specifically those across the lifespan and not just after the addiction has occurred (Mousteri, 2019). This framework also ties into the KAWA model 8 because these moments across the lifespan could be considered the obstacles or rocks presented in the KAWA model. Program Design After meeting with Ms. Dugger, reviewing the results of the residents modified interest checklists, and completing research regarding occupational therapys role in substance use disorder, I identified the type of project I wanted to plan and implement. I determined that a sixweek program related to discovering new occupations and overall wellness would be most beneficial for the residents at the Dove Recovery House. I wanted to focus on the needs of the residents in a holistic scope; therefore, I wanted to target multiple areas of wellness and selfdiscovery. The results of the modified interest checklist demonstrated that the residents were interested in activities such as physical activity, arts and crafts, baking, and home maintenance. Therefore, I wanted to relate the six sessions together and demonstrate the importance of a holistic client view. As an outcome assessment, I chose to administer short quizzes at the beginning and end of the session to determine the residents prior knowledge and knowledge gained of the subject we covered that day. The answers to the quizzes were covered throughout the session and reviewed with the residents. Finally, I wanted to receive feedback on the program altogether, so I administered an open-ended survey on what I could improve as a program leader, what the residents found most and least helpful, and what they would change in future programs. 9 Program Implementation The program consisted of one session per week for an hour to allow enough time to cover the materials and participate in activities. Ms. Dugger and I decided that Monday mornings at 10 am would be the best time for the residents to meet due to their busy schedules. The residents all met in the common space at the house. I would begin the session with attendance and a presentation about the topic of the day. After the presentation, there would be an activity related to the main topic. I provided all the materials necessary to complete the daily activities and presentations. Project Outcomes To assess the previous and current occupations performed by clients at Dove Recovery House, I used the Modified Interest Checklist. The results of the Modified Interest Checklist determined that the clients were primarily interested in activities pertaining to health and wellness, home management, and leisure. These results guided my selection of session topics to make the sessions more interesting and enjoyable for the clients. Over the span of six sessions, I utilized pre-and post-session quizzes to assess prior knowledge of the topics and knowledge gained. I used five multiple-choice questions on each quiz that assessed the basic elements of the topic we were covering for the day. On average, the clients scored an 80% on the pre-session quizzes and 100% on the post-session quizzes. I also utilized a 5 Point Likert scale to assess the clients attitude toward the topic covered each day. These findings can be viewed in Table 1. Likert scales are psychometric scales that assess an individuals opinion or attitude toward a subject (Form Plus Blog, 2019). A study conducted in 2014 found Likert scales to be both reliable and valid in qualitative research (Koksal et al., 10 2014). The results of the Likert scale questions varied from 1-5 but demonstrated an array of knowledge among the clients. To assess the clients overall satisfaction with the six sessions, I once again utilized a Likert Scale and created a satisfaction survey. Surveys can be a significant quality improvement tool, especially in health care environments (Al-Abri & Al-Balushi, 2014). I asked questions pertaining to the sessions being interesting, organized, beneficial, easy to understand, enjoyable, and welcoming. As seen in Table 2, out of the seven respondents, six rated the sessions excellent in the categories of being a welcoming environment, beneficial to their recovery, and enjoyable. Five of the clients felt the sessions were excellent in the organized category, and four felt that the sessions were good for the interest category. I also allowed comments and questions to be written on the survey to assess what I could improve on as a session leader. Summary Substance use disorder is a condition that continues to affect individuals and communities of all backgrounds around the world. Recovery from substance use disorder is a tedious process that can both physically and mentally challenging for individuals. It is not uncommon that those in recovery will relapse at some point, often making overdosing more likely. At Dove Recovery House for Women, the need for programs related to self-sufficiency and sobriety have been at an all-time high due to the current opioid epidemic. After determining the needs of the site through assessment and interviews, I was able to design a program that looks at clients holistically and encourages healthy occupations that the clients find meaningful, as well as discovering new ones. The goal of the program was to reduce the risk factors related to substance use relapse and encourage the discovery of new occupations. 11 The results of the study indicated that many of the clients found the program to be beneficial, enjoyable, and interesting. In addition, the clients reported that they would enjoy a program like the one I designed. These results demonstrate an implication that occupational therapy can benefit those in recovery and that they are skilled to design and implement programs in this setting. Conclusion Overall, the results of this program demonstrated a want from the residents for future programs like this one. The residents reported the program meeting their expectations and being an enjoyable part of their week. In addition, the residents reported finding the resources provided to them to be beneficial in their recovery process. From these results, occupational therapy is a healthcare profession that can benefit clients in recovery from substance abuse. As skilled professionals, occupational therapists are well equipped to assess clients needs and create a program that can assist clients in finding meaningful activities to replace the occupation of addiction. Occupational therapists must advocate for their involvement in this practice area and market their skills and abilities to work with this population. Further research should be conducted on the use of skilled occupational therapy services while planning interventions and program development in the practice area of substance use disorders. 12 References About. The Kawa Model. (2016, August 6). http://www.kawamodel.com/v1/about/#:~:text=The%20Kawa%20Model%20is%20a%20therape utic%20method%20developed,from%20the%20high%20lands%20down%20to%20the%20ocea Al-Abri, R., & Al-Balushi, A. (2014). Patient satisfaction survey as a tool towards Quality Improvement. Oman Medical Journal, 29(1), 37. https://doi.org/10.5001/omj.2014.02 American Psychology Association . (2021). What is a substance use disorder? What Is Addiction? Retrieved January 27, 2022, from https://www.psychiatry.org/patients-families/addiction/whatis-addiction Amorelli, C. R. (2016). Psychosocial occupational therapy interventions for substance-use disorders: A narrative review. Occupational Therapy in Mental Health, 32(2), 167184. https://doi.org/10.1080/0164212x.2015.1134293 Assistant Secretary of Public Affairs (ASPA). (2019). What is the U.S. opioid epidemic? HHS.gov. https://www.hhs.gov/opioids/about-the-epidemic/index.html. Brande, L. (2022). Types of substance abuse treatment programs. Recovery.org. Retrieved February 4, 2022, from https://recovery.org/drug-treatment/types-of-programs/ Cole, M. B., & Tufano, R. (2008). Applied theories in occupational therapy: a practical approach. Slack. Corvinelli, A. (2005). Alleviating boredom in adult males recovering from substance use disorder. Occupational Therapy in Mental Health, 21(2), 111. https://doi.org/10.1300/j004v21n02_01 13 Dugger, C. (2022, January 10) Personal communication [interview]. Dugger, C. (2022, January 14) Personal communication [Personal Interview]. Dugger, C. (2021, March 3) Personal communication [phone]. Form Plus Blog (2019). The 4,5, and 7 point likert scale + [questionnaire examples]. Formplus. Retrieved March 21, 2022, from https://www.formpl.us/blog/point-likertscale#:~:text=A%20commonly%20used%205%20point%20Likert%20scale%20example,that%2 0would%20be%20distinct%20enough%20for%20the%20respondents. Home. Dove Recovery House. (2021, March 4). https://doverecoveryhouse.org/. Hoxmark, E., Wynn, T. N., & Wynn, R. (2011). Loss of activities and its effect on the well-being of substance abusers. Scandinavian Journal of Occupational Therapy, 19(1), 7883. https://doi.org/10.3109/11038128.2011.552120 Koksal, M., Ertekin, P., & Colakoglu, O. (2014). How differences among data collectors are reflected in the reliability and validity of data collected by LikertType scales? Educational Sciences: Theory & Practice. https://doi.org/10.12738/estp.2014.6.2028 Lape, J.E., & Scaife, B.D. (2017) Use of the KAWA model for team-building with rehabilitative professionals: An exploratory study. The Internet Journal of Allied Health Sciences and Practice, 15(1) Mann, B. (2022). There is life after addiction. most people recover. NPR. Retrieved February 4, 2022, from https://www.npr.org/2022/01/15/1071282194/addiction-substance-recovery- 14 treatment#:~:text=More%20than%20a%20million%20Americans%20have%20died%20from,in %20recovery%20after%20some%20form%20of%20substance-use%20disorder. Marshall, C. A., Davidson, L., Li, A., Gewurtz, R., Roy, L., Barbic, S., Lysaght, R. (2019). Boredom and meaningful activity in adults experiencing homelessness: A mixed-methods study. Canadian Journal of Occupational Therapy, 000841741983340. https://doi.org/10.1177/0008417419833402 Mousteri, V., Daly, M., Delaney, L., Tynelius, P., & Rasmussen, F. (2019). Adolescent mental health and unemployment over the lifespan: Population evidence from Sweden. Social Science & Medicine, 222, 305314. https://doi.org/10.1016/j.socscimed.2018.12.030 Peloquin, S. M., Ciro, C. A., Fingerhut, P., & Patterson, T. (2017). Population-centered groups for women recovering from Substance Abuse: Satisfaction, engagement, and lessons learned. Occupational Therapy in Mental Health, 34(2), 138150. https://doi.org/10.1080/0164212x.2017.1398120 People who use drugs are real people. Stop Overdose BC. (2014,). Retrieved February 4, 2022, from https://www.stopoverdose.gov.bc.ca/ Prevention of substance use and mental disorders. SAMHSA. (n.d.). Retrieved January 27, 2022, from https://www.samhsa.gov/find-help/prevention Schepis, T. S., Klare, D. L., Ford, J. A., & McCabe, S. E. (2020). Prescription Drug Misuse: Taking a Lifespan Perspective. Substance Abuse: Research and Treatment, 14, 117822182090935. https://doi.org/10.1177/1178221820909352 15 U.S. National Library of Medicine. (2021). Substance use disorder: Medlineplus medical encyclopedia. MedlinePlus. Retrieved January 27, 2022, from https://medlineplus.gov/ency/article/001522.htm 16 Table 1 Outcomes of Six Sessions Session Topic Pre Test Scores Post Test Scores Likert Scale Ratings (Average) (Average) 1. Mindfulness 80% 100% (Average) 3 2. Health and Wellness 80% 100% 3 3. Cooking and Baking 80% 100% 4 4. Arts and Crafts 80% 100% 3 5. Gardening 80% 100% 4 6. Sleep and Rest 80% 100% 3 Table 2 Results of Satisfaction Survey Likert Scale Question Asked Welcoming Environment Organized Interesting Beneficial Enjoyable Yes or No Question Asked I would like to participate in a program similar to this: Likert Scale Ratings with Number of Respondents Poor (1) Below Average Good (4) Excellent Average (2) (3) (5) 1 1 Yes 7 No 1 6 1 4 1 5 3 6 6 17 This program met my expectations The information was presented in a way that I could understand 7 7  ...

... ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 1 An International Delphi to Establish Priorities for Education, Research, and Practice to Address Sexuality and Intimacy in Occupational Therapy Abbie Alter, Courtney Cummings, Bridget Downs, Kayla Elstien, Irelend Grace Greenwell and Kyli Luna December 2022 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: Beth Ann Walker, PhD, MS, OTR, FAOTA ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 2 A Research Project Entitled An International Delphi to Establish Priorities for Education, Research, and Practice to Address Sexuality and Intimacy in Occupational Therapy 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: Abbie Alter, Courtney Cummings, Bridget Downs, Kayla Elstien, Irelend Grace Greenwell and Kyli Luna Doctor of Occupational Therapy Students Approved by: Beth Ann Walker, PhD, MS, OTR, FAOTA Digitally signed by Beth Ann Walker, PhD, MS, OTR, FAOTA Date: 2022.12.16 17:33:07 -05'00' Research Advisor 12/16/2022 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 ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 3 Abstract Addressing sexuality and intimacy within the scope of occupational therapy has been challenging due to practitioner and client lack of comfort, knowledge, and willingness to begin the conversation surrounding the topic. Literature has demonstrated a call to address sexuality and intimacy, however, there was still a need to further understand the barriers and what was important to best implement sexuality and intimacy into practice. To address this problem, the objective of this study was to utilize the Delphi method to identify research priorities for the international practice of occupational therapy in addressing clients sexuality and intimacy needs. We set out to determine relevant and feasible research priorities across three themes: increasing education of current and future practitioners, advancing the understanding of occupational nature of sexuality and intimacy, and examining current practice trends and interventions to address sexuality and intimacy. Our results show that experts agreed on the need to create new educational standards, and develop greater understanding of the various factors impacting clients occupational nature, which will in turn better enhance clinical practice trends when it comes to addressing sexuality and intimacy. Keywords: sexuality, intimacy, occupational therapy, international delphi approach ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 4 A Delphi Approach to Determine Priorities for Education, Occupational Nature, and Practice to Support the Global Trends of Occupational Therapy in Addressing Sexuality and Intimacy Sexuality is a central facet of the human experience and encompasses gender identities and roles, sexual orientation, intimacy, sexual activities, and reproduction (Hyland & McGrath, 2013; World Health Organization [WHO], 2006). According to the World Health Organization (WHO, 2006), sexuality is defined as an emotional, physical, and mental connection, and all persons have a right to a safe, healthy, respectful sexual relationship that is pleasurable and free from violence and discrimination. Sexuality can be expressed and experienced in many ways, through occupations, desires, behaviors, relationships, thoughts, and values (Gontijo et al, 2015; Hyland & McGrath, 2013). The ability and opportunity to safely express one's sexuality, and to receive education and services for sexual health, is a fundamental right of all human beings despite any illnesses or disabilities (Couldrick, 1998; Lynch & Fortune, 2019; WHO, 2015). Injury, illness, and disability can have an effect on an individual's sexual knowledge, activity, interest, response, expression, self-view, intimacy, family planning and overall wellness (Walker et al., 2020). Despite any new or pre-existing conditions, people continue to be sexual beings and their potential needs or concerns should be addressed during occupational therapy (Lynch & Fortune, 2019; Sakellariou & Sawada, 2006; Young et al., 2020). The focus of occupational therapy is to enhance an individual's ability to independently engage in purposeful and meaningful activities (American Occupational Therapy Association [AOTA], 2014). Sexuality and intimacy fall within the scope of occupational therapy practice as these areas are often part of a fulfilling life for clients and are incorporated in their activities of ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 5 daily living (Lynch & Fortune, 2019; Grasso, 2020). Occupational therapy practitioners are uniquely prepared to address sexuality and intimacy with clients due to the involvement of a variety of client factors, performance skills, possible adaptations, and environmental factors required to engage (Walker et al., 2020). Sexuality and intimacy are a concern for many clients, however, there has been little progress made in the consistency of addressing sexuality and intimacy in practice despite a continuous call (McGrath & Sakellariou, 2016). Perhaps the discrepancy in progress is linked to limitations in academic preparation, limited understanding of the occupational nature of sexuality and intimacy, or evidence examining the development and effectiveness of services provided. The Occupational Therapy Sexual Assessment Framework (OTSAF) was recently developed to provide the framework for occupational therapy involvement in sexuality and intimacy and to guide the creation of the screening tool, the OPISI, to measure occupational performance associated with sexuality and intimacy (Walker et al., 2020). While great movements have been made to change attitudes towards conversations regarding sexuality and intimacy, there is still a significant gap in understanding how to apply the models and tools in practice. For practitioners and students to become more proficient in addressing these topics there is a need for improved educational standards to help facilitate the inclusion of sexuality and intimacy in practice (Duran & Valdes, 2021). The barriers impacting the conversation involving sexuality and intimacy consist of lack of knowledge, comfort, and confidence in addition to lack of training and perceived readiness by both client and therapist (Eglseder & Webb, 2017; Hyland, 2013; McGrath, 2019; Young, 2020). Occupational therapy practitioners agree that addressing sexuality and intimacy in practice is critical, however feel as though the topic was not ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 6 covered in their educational curriculum leading to feelings of unpreparedness (Eglseder & Webb, 2018; Lohman et al., 2017). For example, the Accreditation Council for Occupational Therapy Education Standards (ACOTE), which serves as the accrediting body for educational programs in the US and its territories as well as programs in the United Kingdom, does not include specific standards pertaining to sexuality and intimacy (Eglseder & Webb, 2018). As a consequence occupational therapy practitioners do not feel they possess knowledge of how to effectively address sexual concerns in an intervention program for their clients (Eglseder & Webb, 2018; Sakellariou & Algado, 2006). In order to address the lack of knowledge, literature suggests that more time should be devoted to this topic during school to enhance comfort and willingness of future occupational therapists (Hyland & McGrath, 2013; Jones et al., 2005; Payne et al., 1988). Occupational therapy practitioners need to recognize the importance of sexuality in clients lives through understanding the occupational nature of sexuality and its impact on the quality of life (Gerbild et al., 2016; Javaherian et al., 2008). Due to the lack of understanding the occupational nature of clients, there has been little progress made in the consistency of addressing sexuality and intimacy in practice (McGrath & Sakellariou, 2016). Clients have stated that the largest influences on their sexuality and intimacy journey has been their altered sexual self-view, the society in which they reside, and their experiences within the healthcare system (Thurston et al., 2020). In order to understand and treat the client in a holistic manner, practitioners need to gather information from the client such as client factors, identity, environment, and occupational desires to determine the influences on ones sexuality and intimacy (Lynch et al., 2019; Walker et al., 2020). ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 7 Sexuality and intimacy are not being consistently addressed across the profession of occupational therapy due to various barriers such as lack of comfort and willingness. The practice of occupational therapy should include addressing sexuality and intimacy through the action of providing assessments, interventions, and treatments that are theory based and client centered (Gray, 2021). In order to provide such services, occupational therapy practitioners should create a welcoming therapeutic environment where clients feel free to speak about their sexuality and intimacy concerns (Rose & Hughes, 2018). Acknowledging sexuality early in the rehabilitation process increases willingness for clients to share concerns and allows time for related intervention planning (Sakellariou & Algado, 2006). More specifically, researchers recommend that effective intervention involves occupational therapy practitioners being able to bring up the topic, assess the client, and introduce adaptation strategies (Hyland & McGrath, 2013; McGrath & Sakellariou, 2016). Increased research, program development, and practitioner expertise regarding occupational therapys involvement while treating sexuality concerns is needed to advance education for practice (Eglseder & Webb, 2018; Mohammed, 2017). Clear guidelines and protocols should be developed and put in place to ensure comfort and safety for client and practitioner when addressing sexuality and intimacy (Hyland & McGrath, 2013). It is imperative that occupational therapy practitioners are providing both proactive and meaningful client experiences that welcome the topic of sexuality and intimacy in a way that is comfortable and effective for everyone (Thurston et al., 2020). Occupational therapy practitioners can help ensure client comfort during the conversation of sexuality and intimacy by bringing up the topic first, dispelling stereotypes, and supporting self-esteem (Hyland & McGrath, 2013; McGrath & Sakellariou, 2016). ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 8 The literature highlights many barriers, gaps, and client needs related to addressing sexuality and intimacy in occupational therapy, yet there is limited carryover due to lack of knowledge, confidence, and comfort over the topic of sexuality and intimacy (Eglseder & Webb, 2017; McGrath et al., 2019). With the development of a theoretical framework (OTSAF) and a theoretical-based performance measure (OPISI), a paradigm shift has occurred, igniting the conversation over sexuality and intimacy. Moving forward, a more unified vision for education, research, and practice across the worldwide profession of occupational therapy is needed to ensure forward progression of the conversation addressing sexuality and intimacy. The purpose of this study is to identify research priorities for the international practice of occupational therapy in addressing clients sexuality and intimacy needs. We set out to determine relevant and feasible research questions across three tiers of inquiry: increasing education of current and future practitioners, advancing the understanding of occupational nature of sexuality and intimacy, and examining current practice trends and interventions to address sexuality and intimacy. Method The aim of the larger two-phase international Delphi study was to determine relevant and feasible education, research, and practice priorities to guide the profession of occupational therapy in addressing sexuality and intimacy. The specific objectives of the parent international Delphi study included: Establish educational guidelines to ensure that students/practitioners are adequately prepared to address the sexuality and intimacy needs of clients. Establish research priorities to better understand the occupational nature of sexuality and intimacy. ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 9 Establish research priorities to support best practice in addressing sexuality and intimacy in occupational therapy. A Delphi method was utilized for this study because it is a well established methodology to gather group consensus from experts as they provide opinions during structured rounds with each rounds responses being summarized and reviewed for feedback (Hasson et al., 2000). The Delphi method allows the research team to establish priorities not identified in the existing literature (Virgara et al., 2021). Delphi studies are often used for healthcare issues to inform clinical decision making, practice recommendations, and the development of assessment tools (Junger et al., 2017). The theoretical underpinnings of this study included the social constructivist paradigm. This theory guided the process of collecting data from multiple perspectives due to the wide array of potential experts. Collectively, participants progressed the knowledge and understanding of the topic with the refinement and repetition of items in each round (Junger et al., 2017). The parent study consisted of two phases. Phase 1 comprised a thematic synthesis of the literature to explore the implications for education, occupational nature, and practice. Once extracted, an item pool of priorities were developed for each tier to inform further rounds of the Delphi study. Phase 2 involved three rounds of expert participation. Round 1 included an openended questionnaire asking experts to identify up to five important research priorities, questions, or problem areas related to each tier of inquiry. After Round 1 the literature excerpts were merged with the expert responses to create a new framework. Items were revised into positive solution focused priorities. In Round 2 experts were asked to rate the importance of the identified research priorities from Round 1, provide suggestions to clarify the wording, and had the opportunity to add new items they felt were missing. In Round 3, the newly identified items will ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 10 be sent back to experts for an additional round of agreement. This paper is the report of Phase 1 and Round 1 of Phase 2 of the larger Delphi study. Ethical Considerations The researchers Institutional Review Board (IRB) reviewed the research proposal and it was determined that it did not meet the federal definition for human subjects research, given the purpose of the study did not handle sensitive personal data. All potential experts were provided an informed consent upon invitation to participate in the study. Phase 1 In Phase 1 of the study, the research team utilized a deductive approach to extract priorities of sexuality and intimacy in occupational therapy from the existing literature to explore and extract the implications for education, understanding occupational nature and practice to generate an item pool (Walker et al., 2020).The literature search was conducted using the EBSCO database. A search was completed between sexuality and intimacy and occupational therapy. Researchers utilized inclusion criteria of peer-reviewed articles and the field of occupational therapy. Articles were excluded if they were not available in English. The initial search yielded a large sum of articles (n=8,349). However, after reviewing abstracts and titles, the subsequent exclusion of duplicates, and irrelevant material, 138 articles remained for full-text review. The research team carefully reviewed, appraised, and assessed quality of all articles with 69 excluded based on inclusion/exclusion criteria and 69 were retained for further analyses. Excerpts obtained from the literature review were categorized into three initial tiers: education, occupational nature, and practice. The priorities were synthesized using thematic analysis until evident themes and subcategories emerged in the three tiers of education, occupational nature, and practice (Singer et ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 11 al., 2020). The team used a constant comparative approach until final frameworks emerged for each tier. The resultant themes, categories, and priorities were reviewed separately by a pair of student researchers and then further conferred with the whole research team for agreement on the placement and fit of the priorities. The summary report of all the priorities was sent to the experts for Phase 2 of the study. Figure 1 Flow Diagram of the Thematic Synthesis literature Search Results Phase 1 Thematic Synthesis of Literature The research team analyzed 69 articles and extracted excerpts relevant to the three tiers of inquiry. Within the tier for education, there were 143 excerpts from the literature which were ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 12 reduced to 28 subcategories and eight main themes. Following, in the tier for occupational nature, there were 80 excerpts from the literature which were reduced to 13 subcategories and two main themes. Lastly, the tier for clinical practice, there were 118 excerpts from the literature, which were reduced to 19 subcategories and six main themes. Methods Phase 2 The second phase of this study included three rounds of data collection from experts using Qualtrics Online Survey Software. The software was used to develop, send, and record all data and demographics from the respondents. Online surveys support Delphi methodologies as they enhance the ability to collect a large amount of data over a widespread geographical area, allows for asynchronous participation, is cost effective, and allows ease of data analysis (Holloway, 2012). All electronic data remained password protected and encrypted through Qualtrics Survey Software. The data from each round was de-identified for analysis and only traced back to the experts when there was a need to clarify statements or for member-checking. Throughout the study, responses were not anonymous to researchers however, no personal identification information was shared with other experts. Panel Selection A sample size with a minimum of 10 and a maximum of 50 participants is recommended, as 10 participants does not generate enough ideas and a larger sample size can result in inefficiencies (Shariff, 2015). However, De Villiers et al., (2005) define a sample size as dependent upon the homogeneous or heterogeneous population of the sample and suggest no greater than 15-30 participants if they are from the same discipline. In line with the ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 13 recommendations from the research, the team contacted 35 potential experts within the field of occupational therapy with the aim of a homogenous sample size of 30 potential experts. Recruitment of potential experts was completed through techniques of purposive sampling where the potential experts are selected based on their expertise and fit with the aim of the study (Shariff, 2015). These potential experts were gathered by reaching out to authors of journal articles and conference proceedings to allow for greater expert understanding and quality of findings compared to alternate sampling methods (Anney, 2014). Purposive sampling was followed by snowballing to expand the expert poll, where previously identified authors contacted other potential experts they felt were eligible (Holloway, 2012). Potential experts were emailed an eligibility survey to determine if they meet the criteria for the study. Inclusion criteria included occupational therapists who have established expertise and contributed to the advancement of research, education, and/or practice of occupational therapy in addressing the sexuality and intimacy needs of clients. Potential experts should be able to read and respond in English. If potential experts met the inclusion criteria for eligibility, they were invited to participate in the study and were provided informed consent. Experts provided their name, title, and email address for possible questions or clarification and were notified that personal identification information would not be shared and would be deleted upon conclusion of the study. The final number of experts, their level of expertise, years of experience, and their geographical location are listed in Table 1. Table 1 Number of Experts and Years of Experience Country Number of Experts Years of Experience United States of America 9 185 ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY Australia 4 52.5 Canada 3 40 Argentina 2 23 United Kingdom of Great Britain and Northern Ireland 2 33 Italy 2 19 Israel 1 11 India 2 22 Austria 1 11 Germany 1 3 Namibia 1 13 Total 28 412.5 Table 2 Highest Level of Education Obtained Highest Level of Education Obtained Number of experts Baccalaureate Degree 10 Master's Degree 7 Clinical/Professional Doctorate (OTD, DrOT) 3 Doctor of Occupational Science (ScD) 1 Doctor of Education (EdD) 1 Doctor of Philosophy (PhD) 4 14 ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY Doctor of Health Science (DHS) 2 Total 28 15 Table 3 Highest Level of Education in Occupational Therapy (OT) Highest level of education in OT Number of Experts Doctorate Degree 6 Master's Degree 10 Baccalaureate Degree 10 Certificate 2 Total 28 Round 1 Procedure In Phase 2, Round 1 of the International Delphi study the research team sent the experts an open ended questionnaire where they could identify up to five research topics, questions, or problem areas related to the tiers of education, occupational nature, and clinical practice related to sexuality and intimacy. The research team then analyzed each category of expert responses using apriori coding established from the synthesis of the literature from Phase 1 to assist with merging the two data sets for each category. In the case that multiple experts stated the same topic, the research team reduced the priority so it only appeared once in the data. Once data sets were combined and reanalyzed new patterns began to emerge to better explain the data. Similar to the procedure used to analyze the priorities found in the literature, the large categories of ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 16 education, occupational nature, and practice were triangulated amongst each other to ensure consistency and completeness. The priorities were triangulated with the OTPF and the OTSAF to identify potential gaps. The resultant themes, categories, and priorities were reviewed separately by pairs of doctoral student researchers and the primary investigators until a final framework emerged. Items within each tier were triangulated with each other and the OTPF and OTSAF to ensure consistency and completeness of data (Anney, 2014). The two principal investigators reviewed the identified conceptual gaps and created items matching the content and flow of the tier. The resultant themes, categories, and priorities were reviewed separately by a pair of student researchers and then further conferred with the whole research team for agreement on the placement and fit of the priorities. An action-focused approach to item wording was adopted for all priorities and uniform terminology was used throughout to ensure consistency and flow. Each team member reviewed the pre and post statements to confirm the nature of the priority remained as intended. Rigor As recommended by Anney (2014), trustworthiness criteria including credibility, transferability, confirmability, and dependability were adopted to strengthen the quality of the research findings. To ensure confidence in the research findings credibility strategies of member checking, triangulation, and peer examination were utilized. Member checking was utilized to protect the quality of the results by referring back to the experts when necessary to clarify the interpretation of the responses (Anney, 2014). Responses that needed clarification were separated and the primary investigator referred to the rationale provided by the expert for further understanding or contacted the expert for clarification. The research team consisted of eight ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 17 caucasian, heterosexual females. Although every effort was made, unconscious bias may be present due to the research team's personal views, expertise, and demographics. To mitigate bias, multiple researcher pairs analyzed the same data sets separately with subsequent cross comparison as a form of investigator triangulation (Anney, 2014). Peer examination included discussions of research processes/findings among neutral peers to contribute to a deeper reflexive analysis of the responses (Anney, 2014). Structure of discussion meetings included: weekly primary investigator and research team, weekly primary investigator and co-primary investigator, and combined meetings. Transferability was facilitated by aiming to provide a thick description of the methodology and purposive sampling to protect the generalizability of the results (Anney, 2014). Strategic clarification of the research process and methodology throughout the entirety of the study and documentation of descriptive steps served as an audit trail (Anney, 2014). Confirmability strategies such as reflexive journaling and triangulation were put into place to corroborate that the results and interpretations of this study were not fabricated by the researchers and instead clearly derived from data (Anney, 2014). The research team meticulously provided extensive comments throughout the phases with thoughts, rationale for recategorization of items into better fitting themes, identify gaps that were still present, and provide rationale for tracked changes. These steps further supported the protection of data against individual researcher bias through group discussions (Anney, 2014). Dependability of the research findings relied on interpretations and recommendations of the study being supported by data (Anney, 2014). Evaluation of data included the implementation of peer examination, triangulation, and a code-recode strategy (Anney, 2014). Methodological triangulation or the use of different research methods to analyze information ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 18 within pairs fostered a comprehensive understanding of emerging themes and data patterns among researchers (Anney, 2014). A code-recode strategy was practiced with multiple observations of data where researchers re-observed the excerpts following gestation periods and agreement of interpretation was indicated enhancing the dependability of the results (Anney, 2014). Results Combined Analysis of Literature-Based Priorities with Expert Responses Twenty-eight experts met the criteria for inclusion and participated in the Delphi study. For a detailed account of the results of this study please refer to the Appendix. For the education tier, experts produced 95 priorities and/or problems which were included in the combined analysis. After combining the literature and expert responses, a total of 142 items emerged to capture priorities in this area which were reduced into 33 subcategories and two main themes. For the tier identifying priorities related to determining the occupational nature of sexuality and intimacy, experts produced 92 responses which were extracted for analysis. After combining literature excerpts and expert responses 134 items emerged to explain priorities for this tier, which were reduced to 13 subcategories and five main themes. Experts produced 103 priorities related to guide research to support the practice of occupational therapy in addressing sexuality and intimacy. Following analysis of the combined literature excerpts and expert responses, 104 items emerged, which were reduced to 26 subcategories and nine main themes. Discussion The purpose of the parent two-phase international Delphi study was to determine relevant and feasible education, research, and practice priorities to guide the profession of occupational ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 19 therapy in addressing sexuality and intimacy. This paper is the report of Phase 1 and the first round of an International Delphi study (Phase 2). Phase 1 included a thematic synthesis of the literature to extract priorities relevant to each tier of inquiry. Round 1 of Phase 2 included an open-ended questionnaire asking experts to identify up to five important research priorities, questions, or problem areas related to each tier of inquiry. Phase 1 results were merged with Round 1 results and analyzed until a unified list of priorities relevant to each tier emerged to capture salient priorities. The results of this analysis were sent to experts for the next round of the international Delphi study. Prior to this study, existing literature stated a need for an improvement in the educational curriculum provided in OT programs about addressing sexuality and intimacy. Specifically, there is a need for occupational therapists to be better prepared while they are students about sexuality and intimacy. This can be done through the implementation of Accreditation Council for Occupational Therapy Education (ACOTE) standards to teach in U.S. schools and other educational standards in programs across the world (Lohman et al., 2017). In addition, research has suggested that textbooks and assessment tools being utilized in curriculum need to emphasize the significance of sexuality of clients by more frequently discussing the importance (OMullan et al., 2021). Throughout our analysis, experts have agreed that there is a need to assess the current pedagogy and curriculum in addition to redesigning such programs with the use of universal terminology guided by the OTSAF. In order to fill the additional gaps of the curriculum, experts stated a need for professional opportunities, such as fieldwork and practical applications, an increase for advocacy and understanding of the occupational therapy process from the initial screening to discharge, and to further understand the barriers (comfort, attitude, confidence, willingness, lack of knowledge, and competency) to addressing the conversation ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 20 about sexuality and intimacy from the perspective of practitioners, students, and clients. There is a need to determine educational training programs to address the comfort and knowledge of occupational therapists while discussing sexuality and intimacy (Fortinsky & Shaham, 2020; McGrath & Sakellariou, 2016). Education is needed to understand the complexities of occupational nature as it relates to the OTSAF components. In order to better address and discuss sexuality and intimacy with patients in practice, there is a need to understand how their occupational nature impacts the topic. Through analysis of literature and expert responses it was discovered that it is important to understand overall client comfort, client factors, environmental factors, sexual occupations in regards to knowledge, self-view, activity, expression, health, intimacy, and family planning. It has been reported that many clients want to discuss their sexuality and intimacy concerns however are hesitant due to the stigma and social norms surrounding the topic (McGrath & Sakellariou, 2016; McGrath et al., 2019; Nilsson et al., 2017). The experts agreed that there continues to be a need to understand the client comfort level and the factors that influence this in regard to addressing sexuality and intimacy. In addition, research has suggested that in order to understand the individual occupational nature of clients factors such as gender, race, social, physical, and spirituality must be addressed (Twinley, 2014) Our study, also, determined a need to understand the diverse nature of different client factors that impacts an individuals sexual response, interest, and activity. Understanding this diversity is an important part of appreciating how the lived experiences, such as change in health, sexual preference, and individual roles, affects a clients occupational nature. It is also important to understand performance skills and patterns that will impact occupations and non-OTSAF occupations that are associated with sexuality and intimacy. ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 21 There is a need to continue to raise awareness and explore the variety of individuals occupational nature that impacts the topic around sexuality and intimacy. By understanding the occupational nature of the client, we can determine how to provide evidence-based practice addressing sexuality and intimacy. Following our analysis, there is a continued need to develop and assess effective practical interventions and strategies focused on sexuality and intimacy concerns. Through our analysis, there are significant needs outlined pertaining to establishing a safe therapeutic environment, evaluating the effectiveness of current assessments and interventions, practice interventions relating to principles involved in the OTSAF and how the profession as a whole disseminates and advocates for continued practice addressing the topic. Existing research has emphasized the importance of having spaces for clients to openly communicate about sexuality and intimacy and the need to create more safe, inclusive environments (Beagan et al., 2013; Lindsay, 2021; Rose & Hughes, 2018). Our study found that barriers including decreased confidence, willingness, and comfort over the topic of sexuality and intimacy can be significantly reduced through the creation of a therapeutic environment, leading towards a more comprehensive practice. Moving forward, researchers stated that occupational therapists need to incorporate assessments and interventions related to sexuality and intimacy in order to fully achieve holistic, client-centered care addressing activities of daily living (Auger, 2019; Gray, 2021; Fouche, 2014; McGrath & Sakellariou, 2016; Zhagan, 2013). Furthermore, Gray (2021) referenced that occupational therapists need to address sexuality as it is part of our scope of practice and utilize the OTPF as a guide for developing interventions. Upon examination of our study, experts have agreed that there is a need to identify the availability of tools and resources in addition to utilizing effective guidelines such as the OTPF and OTSAF for universal commonality amongst healthcare professionals to guide ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 22 practice. It has also been identified that there is a need to create pathways for continued care where sexuality and intimacy needs are prioritized along with discharge plans and referrals as appropriate to maintain client-centered care. Previous literature has expanded on the need to prioritize sexuality and intimacy as it is within our scope of practice and relates to occupational performance and for therapist to advocate for their clients sexual rights to meet such participation goals of our clients (Curtis & Morris, 2015; Gray, 2021; McGrath & Sakellariou, 2016). The experts in our study have determined there is a need in the profession to advocate for sexuality and intimacy inclusion through the use of media and curriculum advancements both locally and globally to continue to define OTs role in addressing sexuality and intimacy to improve clientcentered, holistic practice Limitations While our study involved a well rounded international panel of experts, one limitation of the study was that we only represented occupational therapists from 11 countries with the feedback heavily dominated by the United States responses. The study required that the participants be able to read and write in English in order to participate. Furthermore, the researchers were all white heterosexual women which could lead to unintentional biases throughout the study. To mitigate these limitations, the results were guided by experts and literature. When researchers analyzed and modified the results they used investigator triangulation to reduce unintentional bias. Future Research This study plays a role in a larger parent study where Rounds 2 and 3 of Phase 2 will take place to identify highest priorities to address when it comes to education, understanding ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 23 occupational nature, and practice implementations. Future research calls for the continuation of action to be taken based on the priorities discovered in this comprehensive study. Actions consist of developing educational curriculums that address sexuality and intimacy, understanding the diversity of the occupational nature of a client, and determining the effectiveness of evidencebased practice in the development of assessments and interventions. Conclusion In conclusion, there are a variety of gaps in the education surrounding sexuality and intimacy, the understanding of the occupational nature of a client, and the effectiveness of clinical practice addressing sexuality and intimacy. Our study has paved the pathway in addressing identified gaps by producing a list of needs in order to begin to take action as a profession. Through the combination of previous literature analysis and our studys results from experts in the field, it is clear the importance of our role as occupational therapists globally to address sexuality and intimacy for holistic, client centered care. ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 24 References Alonso, N. R., Francisco de Miguel, M. I., Garlito, P. A., & Garcia, T.P. (2021). An occupational therapy approach to sexuality in people with acquired brain injury in a subacute setting. Sexuality and Disability, 39, 181-194. American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1S48. https://doi.org/10.5014/ajot.2014.682006 Anney, V.N. 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Stroke, 51(10), e273e275. https://doi.org/10.1161/STROKEAHA.120.030828 ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 34 Nilsson, M. I., Fugl-Meyer, K., von Koch, L., & Ytterberg, C. (2017). Experiences of sexuality six years after stroke: A qualitative study. Journal of Sexual Medicine, 14(6), 797803. https://doi.org/10.1016/j.jsxm.2017.04.061 OMullan, C., OReilly, M., & Meredith, P. (2021). Bringing sexuality out of the closet: What can we learn from occupational therapists who successfully address the area of sexuality in everyday practice? Australian Occupational Therapy Journal, 68(3), 272281. https://doi.org/10.1111/1440-1630.12723 Palacios-Cea, D., Losa-Iglesias, M. E., lvarez-Lpez, C., Cachn-Prez, M., Reyes, R. A. R., Salvadores-Fuentes, P., & Fernndez-de-las-Peas, C. (2011). Patients, intimate partners and family experiences of implantable cardioverter defibrillators: Qualitative systematic review. 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Approach to sexuality from occupational therapy in people with acquired brain injury in subacute stage: Study protocol. International Journal of Qualitative Methods, 19, N.PAG. https://doi.org/10.1177/1609406919899221 Rolland, J. P., Myrberget, M.-A., & Meisingset, T. W. (2021). The assistive device situation for ALS patients in Norway. Occupational Therapy International, 15. https://doi.org/10.1155/2021/5563343 Rose, N., & Hughes, C. (2018). Addressing sex in occupational therapy: A coconstructed autoethnography. The American Journal of Occupational Therapy : Official Publication of the American Occupational Therapy Association, 72(3), 7203205070p1-7203205070p6. https://doi.org/10.5014/ajot.2018.026005 Rosenbaum, T., Vadas, D., & Kalichman, L. (2014). Sexual function in poststroke patients: Considerations for rehabilitation. Journal of Sexual Medicine, 11(1), 1521. https://doi.org/10.1111/jsm.12343 Sakellariou, D., & Algado, S. S. (2006). Sexuality and occupational therapy: Exploring the link. British Journal of Occupational Therapy, 69(8). Sakellariou, D., & Sawada, Y. (2006). Sexuality after spinal cord injury: The Greek males perspective. American Journal of Occupational Therapy, 60, 311319. Seymour, L. M., & Wolf, T. J. (2014). Participation changes in sexual functioning after mild stroke. OTJR: Occupation, Participation and Health, 34(2), 7280. ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 36 Shariff, N. (2015). Utilizing the delphi survey approach: A review. J Nurs Care, 4(3), 246-251. Available at: http://ecommons.aku.edu/eastafrica_fhs_sonam/38 Shikako-Thomas, K., Bogossian, A., Lach, L. M., Shevell, M., & Majnemer, A. (2013). Parents perspectives on the quality of life of adolescents with cerebral palsy: Trajectory, choices and hope. Disability and Rehabilitation, 35(25), 21132122. https://doi.org/10.3109/09638288.2013.770083 Singer, I., Klatte, I., S., Welbie, M., Cnossen, I., C., & Gerrits, E. (2020). A multidisciplinary delphi consensus study of communicative participation in young children with language disorders. Journal of Speech, Language and Hearing Research, 63, 1793-1806. Stead, A., & White, J. (2019). Loss of intimacy: A cost of caregiving in Aphasia. Topics in Language Disorders, 39(1), 5570. https://doi.org/10.1097/TLD.0000000000000175 Tabassum, K., Fox, J., Fuller, S., & Hynes, S. M. (2021). Dating with a diagnosis: The lived experience of people with multiple sclerosis. Sexuality & Disability, 118. https://doi.org/10.1007/s11195-021-09698-9 Taylor, B. (2011). The impact of assistive equipment on intimacy and sexual expression. The British Journal of Occupational Therapy, 74(9), 435442. https://doi.org/10.4276/030802211X13153015305637 Tibaek, S., Gard, G., Dehlendorff, C., Iversen, H. K., Erdal, J., Biering-Srensen, F., Dorey, G., & Jense, R. (2015). The effect of pelvic floor muscle training on sexual function in men with lower urinary tract symptoms after stroke. Topics in Stroke Rehabilitation, 22(3), 185193. https://doi.org/10.1179/1074935714Z.0000000019 ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 37 Thurston, C., Blom, L., Conradsson, D. M., & Joseph, C. (2020). Sex, support and society: A journey to reclaiming sexuality for individuals living with paraplegia in Cape Town, South Africa. Spinal Cord, 59(2), 225233. https://doi.org/10.1038/s41Sex, support and society: a journey to reclaiming sexuality for individuals living with paraplegia in Cape Town, South Africa | Spinal Cord393-020-00558-5 Twinley, R. (2014). Sexual orientation and occupation: some issues to consider when working with older gay people to meet their occupational needs. British Journal of Occupational Therapy, 77(12), 623625. https://doi.org/10.4276/030802214X14176260335381 Virgara, R., Phillips, A., Lewis, L., Richardson, M., & Maher, C. (2021). Development of Australian physical activity and screen time guidelines for outside school hours care: An international Delphi study. The international journal of behavioral nutrition and physical activity, 18(1), 3. https://doi.org/10.1186/s12966-020-01061-z Wachspress, B., Maeir, A., & Mazor-Karsenty, T. (2019). Content validity of the parentship protocol: A multidimensional intervention for parents of adolescents with high-functioning autism spectrum disorder. Physical & Occupational Therapy in Pediatrics, 39(4), 373387. Walker, B., Otte, K., LeMond, K., Hess, P., Kaizer, K., Faulkner, T., & Christy, D. (2020). Development of the occupational performance inventory of sexuality and intimacy (OPISI): Phase one. The Open Journal of Occupational Therapy, 8(2), 1-18. https://doi.org/10.15453/2168-6408.1694 ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 38 World Health Organization. (2006). Defining sexual health: Report of a technical consultation on sexual health 28-31 January 2002, Geneva. https://www.who.int/reproductivehealth/publications/sexual_health/defining_sexual_heal h.pdf?ua=1 Young, K., Dodington, A., Smith, C., & Heck, C. S. (2020). Addressing clients sexual health in occupational therapy practice. Canadian Journal of Occupational Therapy. Revue Canadienne dergotherapie, 87(1), 5262. https://doi.org/10.1177/0008417419855237 Zhagan, M. (2013). Understanding of parents and adults on the down syndrome female sexual reproductive health. Malaysian Online Journal of Educational Sciences, 1(4), 4856. * BOLD references were used in the thematic analysis of the literature within Phase 1 of the study, see on Figure 1 Appendix An International Delphi Study to Identify Research Priorities for Addressing Sexuality and Intimacy in Occupational Therapy Beth Ann Walker, PhD, MS, OTR & Jenn Soros, PhD, OTR/L The following is a compiled list of research questions and areas of need surrounding occupational therapy and sexuality and intimacy based on the first round of responses from the panel experts and the existing literature. The responses are presented across three pillars of practice: understanding the occupational nature of sexuality and intimacy, support for clinical practice trends, and education of current and future practitioners. Understanding the occupational nature of sexuality and intimacy is presented as relevant and feasible research ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 39 questions. Support for clinical practice trends and education of current and future practitioners are presented as statements based on areas of need. If you have any questions about the questions/statements listed in this document please contact: Beth Ann Walker, PhD, MS, OTR: walkerba@uindy.edu; (317) 788-3428 Jenn Soros, PhD, OTR/L: j.soros@csuohio.edu; (216) 687-3512 ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 40 Understanding the Occupational Nature of Sexuality and Intimacy 1. Person 1.1. Client Comfort 1.1.1. What is the client's comfort level communicating with partners about sexuality/intimacy partners? 1.1.2. What is the clients comfort level with communicating with healthcare professionals about sexuality/intimacy? 1.1.3. What influence do the following factors have on client comfort addressing Sexuality/Intimacy in OT?: 1.1.3.1. Norms 1.1.3.2. Biases 1.1.3.3. Communication barriers 1.1.3.4. Stigma 1.1.3.5. Embarrassment 2. Client Factors 2.1. Sexual Knowledge 2.1.1. What is the sexual health literacy of clients? 2.1.2. What are the client pathways for self-driven learning and drawn conclusions on how to re-engage (what do they learn on their own, google, etc. - without direct intervention). 2.1.3. What are the challenges faced in obtaining sexual knowledge from a comprehensive and developmental point of view for individuals with and without disabilities? 2.1.4. What are the needs of different populations related to sexual knowledge? 2.1.5. How do certain symptoms, challenges, limitations, or client factors influence sexual knowledge? 2.1.6. What is the influence of (partner/caregiver) biased views and beliefs about sexuality and intimacy have on client sexual knowledge and sexual belief? 2.1.7. How has client sexual knowledge changed throughout their lifespan? 2.1.8. What is the importance, meaning, and value of sexuality and intimacy to clients? 2.1.9. What is the influence of parent/guardian views, fear, denial, etc. on individuals with disabilities' understanding of sexuality/intimacy? 2.1.10. What influence does sexual trauma have on client knowledge, beliefs, and attitudes regarding sexuality/intimacy? 2.1.11. What concerns do clients have regarding how their condition influences sexuality and intimacy? 2.2. Sexual Self View ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 41 2.2.1. What are the challenges faced related to sexual self-view from a comprehensive and developmental point of view for individuals with and without disabilities? 2.2.2. What are the needs of different populations related to sexual self-view? 2.2.3. How do certain symptoms, challenges, limitations, or client factors influence sexual self-view? 2.2.4. What concerns do clients have in regards to various aspects relevant to sexual self-view, including: 2.2.4.1. Sexual identity 2.2.4.2. Gender identity 2.2.4.3. Disability identity 2.2.4.4. Sexual Self-esteem which includes self-confidence 2.2.4.5. Body image 2.2.4.6. Self-concept 2.2.5. What influence do the following client factors have on clients sexual selfview: 2.2.5.1. Mental functions (ie, cognitive deficits, Depression, Anxiety (including performance anxiety), Fear) 2.2.5.2. Sensory functions 2.2.5.3. Neuromuscular and movement functions 2.2.5.4. Condition symptoms 2.2.5.5. Voice/speech functions 2.2.5.6. Body structures 2.2.5.7. Skin and related structure functions 2.2.5.8. Pain 2.2.6. What influence do the following contextual factors have on client sexual self-view: 2.2.6.1. Isolation 2.2.6.2. Social support 2.2.6.3. Cultural norms 2.2.7. What influence do occupations or loss of occupations have on sexual self-view? 2.2.8. What is the sexual self-view of transgender and non/binary individuals across various phases of transition and identity development? 2.2.9. How does sexual self-view influence the perception of and participation in occupations? 3. Body Structure/Functions 3.1. Sexual Interest 3.1.1. What are the challenges faced related to sexual interest from a comprehensive and developmental point of view for individuals with and without disabilities? 3.1.2. What are the needs of different populations related to sexual interest? ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 3.1.3. 3.1.4. 3.1.5. 3.1.6. 3.1.7. 3.1.8. 3.1.9. 3.1.10. 3.1.11. 3.2. 4. 42 How do certain symptoms, challenges, limitations, or client factors influence sexual interest? What influence does a new injury, diagnosis, symptoms have on client/partner sexual interest and satisfaction with sexuality/intimacy? What are the supports and barriers affecting sexual interest and satisfaction with sexuality and intimacy for individuals and couples? How does sexual interest change over time following the onset of injury/disability/aging etc.? Is there a relationship between low sexual interest and patterns of avoidance (avoidant attachment disorders, sexual trauma, fear, etc.)? How do clients use eroticism to influence sexual interest? What concerns do clients have regarding the influence of their condition on sexual interest? How does sexual interest affect engagement in sexual activities? How does sexual interest affect intimacy? Sexual Response 3.2.1. What are the challenges faced related to sexual response from a comprehensive and developmental point of view for individuals with and without disabilities? 3.2.2. What are the needs of different populations related to sexual response? 3.2.3. How do certain symptoms, challenges, limitations, or client factors influence sexual response? 3.2.4. What influence does a condition, injury, etc. have on sexual response such as sexual response pathways that lead up to and occur during sexual arousal? 3.2.5. What are the perceptions of clients who experience sexual dysfunction? 3.2.6. How does sexual dysfunction (erectile dysfunction, vaginismus, incontinence, hypoactive sexual desire disorder, genital arousal disorder, orgasm disorder, premature ejaculation, vulvodynia, etc.) influence participation in sexuality/intimacy? 3.2.7. What concerns do clients have regarding the influence of their condition on sexual response? 3.2.8. How do a clients sensory preferences (including hyper/hyporeactivity to sensory input) and regulation needs affect sexual response? 3.2.9. What influence do medications have on sexual response of clients? Environmental Factors 4.1. What is the influence of environmental and contextual factors on the experience of sexuality/intimacy and participation, including: 4.1.1. Products and technology 4.1.2. Support and relationships 4.1.3. Attitudes of others (cisnormativity/heteronormativity, societal views, etc.) 4.1.4. Services/systems/policies ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 4.1.5. 43 Physical environment (long-term care settings, low privacy environments, group homes, etc.) 5. Personal factors 5.1. What is the influence of various personal factors of context on sexuality and intimacy, including: 5.1.1. Age 5.1.2. Sexual orientation 5.1.3. Gender identity 5.1.4. Race/ethnicity 5.1.5. Cultural identification/attitudes 5.1.6. Social background/SES 5.1.7. Upbringing and Life experiences (sexual violence, etc.) 6. Occupation 6.1. Sexual Activity 6.1.1. How do clients define and perceive sexual activity? 6.1.2. What are the variety of sexual activities that clients participate in? 6.1.3. What are the challenges faced related to sexual activity from a comprehensive and developmental point of view for individuals with and without disabilities? 6.1.4. What are the needs of different populations related to sexual activity? 6.1.5. How do certain symptoms, challenges, limitations, or client factors influence sexual activity? 6.1.6. How do clients maintain safety and/or determine the safety concerns associated with the variety of sexual activities clients participate in? 6.1.7. What is the impact of assistive devices and equipment, used for other occupations, on sexual activity (for example does hospital bed interfere with sexual activity for couples)? 6.1.8. What is clients awareness, use, and understanding of sexual devices and other equipment? 6.1.9. What is the developmental sequence of participation in sexual activities for clients? 6.1.10. What barriers and supports to sexual activity do clients experience? 6.1.11. How does participation in SA change following the onset of a clients condition? 6.1.12. What concerns do clients have regarding participation in sexual activity? 6.2. Sexual Expression 6.2.1. What is the relationship between sexual self-view and sexual expression? 6.2.1.1. What impact does transgender identity have on sexual expression? 6.2.2. What occupations, behaviors, mannerisms, preferences, appearance, pronouns, political engagement, acquired tendencies, daily routines, ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 6.2.3. 6.2.4. 6.2.5. 6.2.6. 6.2.7. 6.2.8. 6.2.9. 6.3. 44 symbolic actions, preferred roles do clients identify as conveying their sexual identity? How does sexual expression affect engagement in occupations? What are the challenges faced related to sexual expression from a comprehensive and developmental point of view for individuals with and without disabilities? What are the needs of different populations related to sexual expression? How do certain symptoms, challenges, limitations, or client factors influence sexual expression? What barriers and supports (including environmental, social, occupational injustices, etc.) exist which interfere with a clients ability to express their sexuality? How does perceived gender-based occupational deprivation due to condition influence sexual expression? What concerns do clients have related to their ability to express themselves as a sexual being? Intimacy 6.3.1. How do clients define intimacy? 6.3.2. What are the challenges faced related to intimacy from a comprehensive and developmental point of view for individuals with and without disabilities? 6.3.3. What are the needs of different populations related to intimacy? 6.3.4. How do certain symptoms, challenges, limitations, or client factors influence intimacy? 6.3.5. What concerns do clients have in regards to the occupation of intimacy? 6.3.6. What concerns do clients have in regards to the occupation of dating? 6.3.7. What is the influence of daily occupations and occupational roles on intimacy? 6.3.8. How is intimacy mediated through digital technologies? 6.3.9. What and how do occupations build intimacy? 6.3.10. What are the developmental needs related to intimacy - lifespan development? 6.3.11. What are the communication barriers among clients/partners 6.3.12. What influence does client condition (dx, survivorship, etc.) have on developing and maintaining meaningful relationships? 6.3.13. What strategies do clients use to develop and maintain intimacy? 6.3.14. How do clients/caregivers with disease/disabilities maintain intimacy in their relationships? 6.3.15. What is the clients need for opportunities to develop intimate relationships among clients with intellectual and developmental disabilities? 6.3.16. What are parent/guardian concerns related to their childs desire for developing intimate relationships? ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 6.3.17. 6.3.18. 45 How does caregiver stress influence intimate relationships? What are the environmental barriers to intimacy (hospital beds, equipment, etc.)? 6.4. Sexual Health 6.4.1. What are the challenges faced related to sexual health from a comprehensive and developmental point of view for individuals with and without disabilities? 6.4.2. What are the needs of different populations related to sexual health? 6.4.3. How do certain symptoms, challenges, limitations, or client factors influence sexual health? 6.4.4. What concerns do clients/caregivers have in regards to how their condition impacts sexual health? 6.4.5. What sexual health information and education do clients/parents/caregivers need in relation to development (puberty) (ie ID/DD)? 6.5. Family Planning 6.5.1. What impact do certain conditions have on a persons ability to develop, manage, and maintain routines associated with family planning (including pregnancy prevention)? 6.5.2. What are the challenges faced related to family planning from a comprehensive and developmental point of view for individuals with and without disabilities? 6.5.3. What are the needs of different populations related to family planning? 6.5.4. How do certain symptoms, challenges, limitations, or client factors influence family planning? 6.5.5. What concerns do clients have regarding the impact their condition has on family planning? 6.5.6. How do occupations change during pregnancy, menopause, etc.? 6.5.7. What is the experience of clients who are parents at specific milestones: (pregnancy management, delivery, infant care, early childhood, teens, etc.)? 6.6. Non-OTSAF Occupations 6.6.1. What occupations (excluding sexual activity, intimacy, and sexual expression) are influenced by or associated with sexuality and intimacy? (ie dressing, grooming, health management) 6.7. Performance skills 6.7.1. What are the motor, sensory, and process skills/strategies needed to facilitate sexuality and intimacy? ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 6.8. 46 Performance patterns 6.8.1. What roles, routines, habits, and rituals influence sexuality and intimacy and enable positive sexual experiences? ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 47 Support for Clinical Practice Trends 1. Practitioner focused 1.1. Develop and evaluate efforts to understand sexual safety of staff when addressing Sexuality/Intimacy. 1.2. 2. Develop and evaluate efforts related to self-assessment and critical self-reflection of practitioner competency in addressing sexuality/intimacy. Establishing the therapeutic environment/Therapeutic Use of Self 2.1. Develop and Evaluate the effectiveness of efforts aimed to reduce known barriers to addressing Sexuality/Intimacy in OT practice (attitudes, confidence, willingness, comfort, communication skills) within clinical settings/practice. 2.2. Develop and evaluate the effectiveness of cultural humility training on the inclusive practice of OT in addressing Sexuality/Intimacy in clinical practice. 2.3. Develop and evaluate the effectiveness of programming to mitigate implicit bias of practitioners. 2.4. Development and evaluation of therapeutic environments for the delivery of OT sexuality/intimacy services - safe and inclusive. 2.5. 2.6. Develop and assess the effectiveness of an updated OT-specific PLISSIT model for introducing and addressing sexuality/intimacy in OT. 2.5.1. Including pathways for initiating and addressing the topic in different clinical environments. 2.5.2. Including pathways for initiating and addressing the topic with different client populations. 2.5.3. How to be mindful of complex sexual histories to be sensitive and create a positive therapeutic relationship? Are occupational therapists practicing in the area of sexuality focused more on eliminating inappropriate sexual behaviors rather than promoting pleasure and satisfaction? 3. Setting 3.1. Identify what OT settings deliver sexuality/intimacy services 4. Domain 4.1. Environment/ Context 4.1.1. Explore the impact peer groups interventions and relationships with other patients in clinical settings have on sexual expression. ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 4.1.2. 4.1.3. 48 Develop and evaluate OT services to help the clients social context to respect and support sexuality/intimacy needs of clients. Develop and measure the effectiveness of OT interventions aimed toward environmental and contextual factors. 4.2. Performance skills 4.2.1. Develop and measure the effectiveness of OT interventions aimed toward performance skill training (including motor, sensory, and process skills) related to sexuality/intimacy. 4.3. Performance patterns 4.3.1. Develop and measure the effectiveness of OT interventions aimed at addressing the influence of roles, routines, habits, and rituals on sexuality/intimacy. 5. Process 5.1. Evaluation 5.1.1. Availability/Adoption/Use 5.1.1.1. Identify the availability and use of tools/resources/assessments/intervention strategies available for addressing Sexuality/Intimacy in OT. 5.1.1.2. Develop and evaluate guidelines for conducting Sexuality/Intimacy-based occupational profile (sexual history taking). 5.1.2. Need for Evaluation 5.1.2.1. Explore the effectiveness of screening tools - accurately identify concerns. 5.1.2.2. At what rate do screens lead to OT evaluation and intervention? 6. Intervention Strategy 6.1. Intervention development/timing 6.1.1. Explore the timing of sexuality and intimacy interventions and the impact of timing in order to meet client needs. 6.1.2. Explore how to determine the priority level of services in relation to the time available for service delivery within the context of other OT services (Maslows Hierarchy). 6.2. Intervention Selection 6.2.1. Develop guidelines to determine the best interventions or resources for addressing sexuality and intimacy (Evidence-based practice). 6.3. Equipment 6.3.1. Develop and assess the effectiveness of adaptive equipment designed for sexuality/intimacy. 6.3.1.1. Enhancement - pleasure, performance, positioning, toys, 6.3.1.2. Reduce fear, pain, etc. ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 6.3.2. 7. 49 Develop a catalog or sexuality/intimacy-based product/devices/toys for use in OT applicability to meet the needs of OT consumers and describe the array of adaptive equipment. 6.4. What strategies/interventions are being used 6.4.1. Develop and assess the effectiveness of interventions targeting specific concerns relevant to sexuality/intimacy across populations/diagnoses. (ie for concerns identified on the OPISI/OTSAF related) 6.4.2. Explore the effectiveness of using social scripts or what ifs as an intervention strategy. 6.4.3. Practitioners need to identify appropriate resources and intervention methods using their clinical decision-making while considering diverse client needs. 6.5. Peer groups as intervention 6.5.1. Develop and evaluate the effectiveness of skilled therapeutic peer support groups about sexuality/intimacy across populations/conditions. 6.6. Discharge planning 6.6.1. Create pathways for continuity of care so that the sexuality/intimacy needs of clients are met and prioritized. 6.6.1.1. Develop and evaluate the effectiveness of discharge plans, referrals, continuity of care so it does not get lost in the shuffle. OTSAF 7.1. Sexual knowledge 7.1.1. Develop and assess the effectiveness of educational resources to address concerns/constructs related to sexuality/intimacy across populations/diagnoses (ie concerns noted on OPISI or OTSAF-related). 7.1.2. Determine the depth of content provided to clients in handouts/educational materials based on PLISSIT levels. 7.1.3. Develop and evaluate educational resources available in multiple media formats, languages, and cognitive levels. 7.2. Sexual activity 7.2.1. Identify, develop, and/or explore the effectiveness of interventions related to the sexual activity, task, or environment in which it occurs (positioning, posturing, type of activity, etc.): 7.2.1.1. Positioning 7.2.1.2. Posturing 7.2.1.3. Activity type/Masturbation/intercourse/foreplay 7.2.1.4. Partner vs. non-partnered 7.2.1.5. Proper place and time 7.2.1.6. Timing ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 50 7.2.2. Develop and evaluate protocols for client participation in sexual activity who have certain diagnostic precautions (cardiac, joint mobility, etc.). 7.2.2.1. Cardiac Health and Relationship Management and Sexuality (CHARMS) intervention 7.3. Sexual interest 7.3.1. Develop and evaluate the effectiveness of interventions for sexual interest for various populations/diagnoses/symptoms (stroke, cancer survivorship, pain, fatigue, anxiety, etc.). 7.3.2. Explore the use and effectiveness of education on eroticism as an intervention strategy to impact sexual interest. 7.4. Sexual response 7.4.1. Develop and evaluate the effectiveness of interventions for sexual response. 7.4.2. Develop and evaluate the effectiveness of sensory-based interventions on sexual response. 7.5. Sexual expression 7.5.1. Develop and evaluate the effectiveness of interventions for sexual expression: 7.5.1.1. Disclosing gender identity 7.5.1.2. Developing interpersonal strategies 7.5.1.3. Through ADLs (dressing, grooming, hygiene) 7.5.1.4. Participation in community-based activities Sexual self-view 7.5.2. Develop and evaluate the effectiveness of interventions and/or coping strategies to address sexual self-view: 7.5.2.1. Sexual identity 7.5.2.2. Gender identity 7.5.2.3. Disability identity 7.5.2.4. Sexual Self-esteem, which includes self-confidence 7.5.2.5. Body image 7.5.2.6. Self-concept 7.6. Intimacy 7.6.1. Develop and evaluate the effectiveness of interventions for intimacy: 7.6.1.1. Touch, pleasure, and connection (sensate) 7.6.1.2. Communication strategies 7.6.1.3. Partner education 7.6.1.4. Partner/caregiver strain role/change 7.6.1.5. Planning/adapting dating and/or intimate activities 7.6.1.6. Affection/love language 7.6.1.7. Relationship satisfaction ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 7.6.1.8. 8. 51 Caregiver (non-partner) education on the importance of intimacy for the client 7.7. Sexual health 7.7.1. Develop and evaluate the effectiveness of interventions/educational resources for sexual health in multiple languages, cognitive levels, media formats, etc.: 7.7.1.1. Sexual safety/Safe zones 7.7.1.2. Consent/Exploitation 7.7.1.3. STI/STD prevention 7.7.1.4. Personal hygiene/menstruation 7.7.1.5. Sexual anatomy/sexual development - including masturbation/appropriate time/place 7.7.1.6. Parent/caregiver education 7.7.1.7. Vulnerable populations 7.7.1.8. Privacy 7.8. Family planning 7.8.1. Develop and evaluate the effectiveness of interventions/educational resources for family planning: 7.8.1.1. Pregnancy prevention 7.8.1.2. Pregnancy management 7.8.1.3. Fertility management 7.8.1.4. Parenthood planning Outcomes 8.1. Outcome Measuring 8.1.1. Explore client outcomes of current tools, strategies, interventions, etc. on (OTPF4): 8.1.1.1. Occupational performance 8.1.1.2. Improvement 8.1.1.3. Enhancement 8.1.1.4. Prevention 8.1.1.5. Health and Wellness 8.1.1.6. Quality of Life 8.1.1.7. Participation 8.1.1.8. Role competence 8.1.1.9. Well-being 8.1.1.10. Occupational justice 8.1.1.11. Need to determine reliability and validity of the OPISI ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 9. 52 Profession 9.1. Scope Of PX/Values and beliefs of the profession 9.1.1. Profession needs to disseminate and support the scope/boundaries of OT practice in addressing sexuality and intimacy through a variety of media and curriculum advancements. 9.1.2. Profession should outline potential organizational scope/boundaries that may influence practice. 9.1.3. Profession should advocate for OT's distinct role in addressing sexuality and intimacy. 9.2. International practice 9.2.1. 9.2.2. Profession needs to disseminate and support global perspectives in occupational therapy when addressing sexuality and intimacy. Resources for educating students, practitioners, organizations, and the public regarding the practice of OT in addressing sexuality and intimacy should be available in multiple languages. 9.3. Macro Institutional Support & Global Advocacy 9.3.1. Profession should advocate for a reimagined health care system where the discussion of sexuality and intimacy is normalized. 9.4. Interprofessional Collaborations 9.4.1. Profession should advocate for OTs distinct role in addressing sexuality and intimacy in multidisciplinary collaborations with other healthcare professionals to provide optimum levels of care. ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 53 Education of Current and Future Practitioners 1. Pedagogy 1.1. Curriculum Design 1.1.1. Determine the professional standards for the knowledge skills and attitudes for entry-level practice in addressing sexuality/intimacy in OT. 1.1.2. Develop curriculum standards to assure competency in entry-level practice in addressing sexuality/intimacy in OT. 1.1.3. Develop effective pedagogical strategies to deliver high-quality instruction and foster student competency. 1.1.4. Ethical Considerations: Consider implicit biases of program staff and/or program/institutional culture and values when creating sexuality and intimacy curriculums. 1.2. Assessment of current pedagogy 1.2.1. Explore what is currently being taught in this area 1.2.2. Determine the effectiveness of pedagogical strategies to deliver high-quality instruction and foster student competency. 1.2.3. Explore how should curriculums/educators assess student competency level in addressing sexuality and intimacy needs across populations 1.2.4. Assess student competency level in addressing sexuality and intimacy needs across populations. 1.3. Considerations for curriculum design 1.3.1. Educator 1.3.1.1. Increase the number of faculty who are trained and willing to incorporate sexuality/intimacy content into their courses. 1.3.1.2. Train faculty to discuss, teach, and address sexuality and intimacy with students. 1.3.2. Making it a priority 1.3.2.1. Prioritize curriculum advancements in addressing sexuality/intimacy. 1.3.3. Increase the amount of education/exposure 1.3.3.1. Greater emphasis and access to educational opportunities in this area at entry-level and post-professional level. 1.3.4. Fieldwork 1.3.4.1. Observational and practical application/fieldwork opportunities relevant to the px of OT in addressing sexuality and intimacy. ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 2. 54 Therapist knowledge and expertise 2.1. Scope of Practice/Values and beliefs of the profession 2.1.1. Students/Practitioners should understand the scope/boundaries and timing of OT practice in addressing sexuality and intimacy. 2.1.2. Students/Practitioners should understand the OT process for addressing sexuality and intimacy from screening to discharge. 2.1.3. Students/Practitioners should understand potential organizational scope/boundaries that may influence practice. 2.1.4. Students/Practitioners need to learn skills to advocate for OTs distinct role in addressing sexuality and intimacy. 2.2. Interprofessional Collaborations: 2.2.1. Students/Practitioners need to understand possible multidisciplinary collaborations between the OT and other healthcare professionals discussing sexuality and intimacy concerns with each client to provide optimum levels of care. 2.3. Documentation and Billing 2.3.1. Students/Practitioners need to learn how to write measurable goals regarding sexuality and intimacy that are specific and achievable in multiple practice settings. 2.3.2. There is a need for students/practitioners to understand factors affecting billing and reimbursement for services rendered for addressing sexuality and intimacy. 2.4. Cultural Humility 2.4.1. Ethics 2.4.1.1. Students/Practitioners need to understand that sexuality is an activity of daily living and that it is an area of occupation that applies to holistic client-centered care. 2.4.1.2. Students/Practitioners need to understand the importance and meaning of sexuality and intimacy for clients. 2.4.2. Sexual Rights 2.4.2.1. Students/Practitioners need to understand human sexual rights in order to recognize that sexuality is a fundamental human right regardless of illness or disability. (Non-Judgemental acceptance) 2.4.2.2. Students/Practitioners need to understand the effects of sexual rights violations (including sexual trauma, asexual views, etc.). 2.4.3. Implicit Bias 2.4.3.1. Students/Practitioners need opportunities to explore their own assumptions, prejudices, biases, stigma, and stereotypes regarding sexuality and intimacy. 2.4.3.2. Students/Practitioners need to learn strategies to mitigate their assumptions and implicit biases and teach practitioners to promote ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 55 acceptance of views to increase client comfortability when sharing such self-views. 2.4.4. Increase Exposure to Diversity 2.4.4.1. Students/Practitioners need to be exposed to broad possibilities of culturally diverse perspectives as it relates to sexuality and intimacy. 2.4.4.2. Students/Practitioners need to be aware of how white, heteronormativity, heterosexuality, heterocentrism, homophobia, and minority stress can impact and influence sexual & intimacy norms. 2.4.4.3. Need to expand OT practitioner education in gaining comfortability and competence in addressing sexual expression with all types of individuals. 2.4.4.4. There is a need to explore the sexual self-view of transgender and non/binary individuals across various phases of transition and identity development. 2.4.4.5. Students/Practitioners need to understand and appreciate the need for global perspectives in occupational therapy when addressing sexuality and intimacy. 2.5. Understanding overall barriers to practice 2.5.1. Students/practitioners should understand the barriers to conversations/practice (comfort, attitude, confidence, willingness, lack of knowledge, competence) about sexuality and intimacy from the perspectives of practitioners/students and clients. 2.6. Attitudes 2.6.1. There is a need for students/practitioners to reflect on their own attitudes and biases when addressing sexuality and intimacy issues. 2.6.2. There is a need to foster the attitude that addressing sexuality and intimacy is a legitimate area for practice. 2.6.3. Students/practitioners should be able to identify and challenge negative perceptions surrounding the practice of addressing sexuality and intimacy within OT. 2.6.4. There is a need for education on the importance of expressing attitudes that are respectful, accepting, validating, and affirming when addressing sexuality & intimacy to create a safe and inviting environment for therapeutic intervention. 2.6.5. Students/Practitioners need to understand the sexual rights of individuals and develop skills in communicating these rights in response to stigma surrounding Sexuality/Intimacy within the populations of disability. 2.7. Confidence 2.7.1. There is a need for education and training to increase student/practitioner confidence in discussing and addressing sexuality and intimacy. ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 56 2.8. Willingness 2.8.1. There is a need for students/practitioners to explore their personal values and beliefs, and factors that may influence their willingness/hesitation to address sexuality and intimacy with clients. 2.9. Comfort 2.9.1. There is a need to understand factors that may influence client comfort with therapists regarding the topic of sexuality and intimacy. 2.9.2. There is a need to increase/address the level of student/practitioner comfort when addressing sexuality and intimacy with clients. 2.10. Communication skills 2.10.1. Students/Practitioners need opportunities to develop communication skills/therapeutic use of self skills to address the sensitive nature of sexuality and intimacy with diverse clients across various populations. 2.11. Client-centered and Inclusive Practice Skills 2.11.1. Students/Practitioners need to learn skills and demonstrate competence in providing inclusive and sensitive care when addressing sexuality and intimacy. 2.11.2. Students/Practitioners need skills to create a safe and inclusive space to foster the therapeutic relationship with the client to best address sexuality and intimacy concerns across practice settings. 2.11.3. Students/Practitioners need to learn strategies to enhance client comfort regarding sexuality/intimacy conversations. 2.11.4. Students/Practitioners need to understand the variety of feelings one may have when it comes to sexuality and intimacy and how to address such emotions. 2.11.5. Students/Practitioners need to understand the influence of occupations and/or loss of occupations have on sexuality and intimacy 2.11.6. Students/Practitioners should learn skills for inclusive documentation and advocate for the use of inclusive forms, etc. 2.11.7. Students/Practitioners need to be able to consider complex social systems including families, caregivers, and/or partners because their knowledge, skills, attitudes, and bias may influence the clients experience of sexuality and intimacy. 2.12. Self Advocacy 2.12.1. There is a need to educate students/practitioners on sexual safety in the workplace. 2.12.2. There is a need for students/practitioners to engage in self-reflection of their capabilities and limitations in relation to addressing sexuality and intimacy in practice. 2.12.3. Students/Practitioners need to recognize the limits of their knowledge and expertise or OT scope to make referrals. ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 2.13. 57 Theory-Based Practice 2.13.1.1. Students/Practitioners need to understand the OTSAF constructs/definitions and how they influence each other. 2.13.1.2. Students/Practitioners need to understand how to use the OTSAF to guide the OT process including screen, assessment/reassessment, intervention and discharge planning. 2.13.1.3. Students/Practitioners need to understand how the OTSAF can be used to understand the occupational nature of sexuality/intimacy. 2.13.1.4. Students/Practitioners need to understand how the OTSAF can be used to drive practice. 2.13.1.5. Students/Practitioners should understand how various occupations (excluding sexual activity, intimacy, and sexual expression) are influenced by or associated with sexuality and intimacy. 2.14. Sexual Knowledge 2.14.1. Students/Practitioners need an understanding of human sexual anatomy and development. 2.14.2. Need to define sex terms and appropriate terminology/language when addressing sexuality with clients. 2.14.3. Students/Practitioners need to know how to assess the sexual health literacy of clients. 2.14.4. Students/Practitioners need to understand the influence of culture, context, and environment on an individuals knowledge and beliefs about sexuality/intimacy. 2.14.5. Students/Practitioners need to understand the influence of parent/caregiver knowledge, skills, attitudes, and bias on clients sexual knowledge. 2.14.6. Students/Practitioners need to understand how conditions may influence sexuality/intimacy. 2.14.7. Students/Practitioners need to understand how conditions related to sexual dysfunction influence participation in sexuality/intimacy (erectile dysfunction., vaginismus, incontinence, hypoactive sexual desire disorder, genital arousal disorder, orgasm disorder, premature ejaculation, vulvodynia etc.) 2.14.8. Students/Practitioners need to learn strategies for delivering education, strategies, and intervention on sexuality/intimacy to clients and different levels of health literacy and PLISSIT level (limited information vs specific suggestions) (intensive therapy if trained). 2.15. Sexual Activity 2.15.1. Students/Practitioners need to understand the variety of sexual activities clients participate in - partnered and non-partnered. 2.15.2. Students/Practitioners need to understand the developmental sequence of participation in sexual activities for clients. ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 2.15.3. 2.15.4. 2.15.5. 2.15.6. 2.15.7. 2.15.8. 2.15.9. 2.15.10. 58 Students/Practitioners need to understand the motor, sensory, and process skills/strategies that influence engagement in sexual activity Students/Practitioners need to understand how client roles, routines, habits, and rituals influence engagement in sexual activity. Students/Practitioners should understand common barriers and supports to sexual activity experienced by clients across conditions. Students/Practitioners should understand common concerns clients have in regards to sexual activity. Students/Practitioners need to understand possible safety concerns associated with the performance of sexual activities. Students/Practitioners need to know how to conduct a formal evaluation of client concerns related to sexual activity, interpret results, and write measurable goals. Students/Practitioners need to understand the various types of aids, devices, equipment, and strategies that can be utilized during sexual and intimate activities and when to use them. Students/practitioners need to be exposed to various types/levels of intervention (PLISSIT - Limited Information and/or Specific Suggestions) when addressing sexual activity. 2.16. Sexual Interest/Body Function 2.16.1. Students/practitioners need to understand the stages and types of arousal. 2.16.2. Students/practitioners need to understand how a new injury, diagnosis, symptoms, etc. may influence ct/partner sexual interest and satisfaction with sexuality/intimacy. 2.16.3. Students/Practitioners need to understand the motor, sensory, and process skills/strategies that influence engagement in sexual interest 2.16.4. Students/Practitioners need to understand how client roles, routines, habits, and rituals influence engagement in sexual interest. 2.16.5. Students/practitioners should understand common supports and barriers affecting sexual interest and satisfaction with sexuality and intimacy for individuals and couples. 2.16.6. Students/practitioners should understand common concerns clients have in regards to sexual interest. 2.16.7. Students/Practitioners need to know how to conduct a formal evaluation of client concerns related to sexual interest, interpret results, and write measurable goals. 2.16.8. Students/practitioners need to be exposed to various types/levels of intervention when addressing sexual interest 2.16.9. Students/Practitioners need to understand the various types of aids, devices, equipment, and strategies that can be utilized during sexual interest and when to use them. 2.17. Sexual Response/Body Function 2.17.1. Students/practitioners should understand the different body responses one can have during sexual activities and expressions, what is normal or not. ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 2.17.2. 2.17.3. 2.17.4. 2.17.5. 2.17.6. 2.17.7. 2.17.8. 2.17.9. 2.17.10. 2.17.11. 2.17.12. 2.18. 59 Students/practitioners should understand how a clients sensory preferences (including hyper/hypo reactivity to sensory input) and regulation needs may affect sexual response. Students/practitioners should understand the influence medications may have on the sexual response of clients. Students/practitioners should understand how sexual dysfunction (erectile dys., vaginismus, incontinence, etc.) may influence participation in sexuality/intimacy? Students/practitioners should understand how a new injury, diagnosis, symptoms may influence ct sexual response. Students/Practitioners need to understand the motor, sensory, and process skills/strategies that influence engagement in sexual response Students/Practitioners need to understand how client roles, routines, habits, and rituals influence engagement in sexual response. Students/practitioners should understand common supports and barriers affecting sexual response. Students/practitioners should understand common concerns clients have in regards to sexual response. Students/Practitioners need to know how to conduct a formal evaluation of client concerns related to sexual response, interpret results, and write measurable goals. Students/practitioners need to be exposed to various types/levels of intervention when addressing sexual response. Students/Practitioners need to understand the various types of aids, devices, equipment, and strategies that can be utilized to accommodate sexual response and when to use them. Sexual Expression/Occupation 2.18.1. Students/practitioners should understand the broad possibilities for sexual expression in modern times and how sexual expression of different gender identities may be influenced based on environmental consequences or occupational injustices. 2.18.2. Students/Practitioners need to understand how sexuality is expressed through occupation across the life course, among different populations, and in different sociocultural contexts (McGrath, 2016). 2.18.3. Students/practitioners should understand how a new injury, diagnosis, symptoms may influence sexual expression. 2.18.4. Students/Practitioners need to understand the motor, sensory, and process skills/strategies that influence engagement in sexual expression 2.18.5. Students/Practitioners need to understand how client roles, routines, habits, and rituals influence engagement in sexual expression 2.18.6. Students/practitioners should understand common supports and barriers affecting sexual expression. 2.18.7. Students/practitioners should understand common concerns clients have in regards to sexual expression. ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 2.18.8. 2.18.9. 2.18.10. 60 Students/Practitioners need to know how to conduct a formal evaluation of client concerns related to sexual expression, interpret results, and write measurable goals. Students/practitioners need to be exposed to various types/levels of intervention when addressing sexual expression. Students/Practitioners need to understand the various types of aids, devices, equipment, and strategies that can be utilized to accommodate sexual expression and when to use them. 2.19. Sexual Self-View/Client Factor/Personal factor context 2.19.1. Students/practitioners need to understand concepts relevant to sexual self-view such as Sexual identity Gender identity, Disability identity, Sexual Self-esteem which includes self-confidence, Body image, Self-concept. 2.19.2. Students/practitioners should understand how a new injury, diagnosis, symptoms may influence sexual self-view. 2.19.3. Students/Practitioners need to understand the motor, sensory, and process skills/strategies that influence engagement in sexual self-view. 2.19.4. Students/Practitioners need to understand how client roles, routines, habits, and rituals influence engagement in sexual self-view. 2.19.5. Students/practitioners should understand common supports and barriers affecting sexual self-view 2.19.6. Students/practitioners should understand common concerns clients have in regards to sexual self-view. 2.19.7. Students/Practitioners need to know how to conduct a formal evaluation of client concerns related to sexual self-view, interpret results, and write measurable goals. 2.19.8. Students/practitioners need to be exposed to various types/levels of intervention when addressing sexual self-view. 2.20. Intimacy 2.20.1. Students/practitioners should understand the broad spectrum of possibilities for intimacy and the difference between intimacy and sexual activity. 2.20.2. Students/practitioners should understand how a new injury, diagnosis, symptoms may influence intimacy for client and/or partner 2.20.3. Students/Practitioners need to understand the motor, sensory, and process skills/strategies that influence engagement in intimacy. 2.20.4. Students/Practitioners need to understand how client roles, routines, habits, and rituals influence engagement in intimacy. 2.20.5. Students/practitioners should understand common supports and barriers affecting client/partner intimacy. 2.20.6. Students/practitioners should understand common concerns clients and/or their partners have in regards to intimacy. 2.20.7. Students/Practitioners need to know how to conduct a formal evaluation of client concerns related to intimacy, interpret results, and write measurable goals. ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 2.20.8. 2.20.9. 61 Students/practitioners need to be exposed to various types/levels of intervention when addressing intimacy. Students/Practitioners need to understand the various types of aids, devices, equipment, and strategies that can be utilized to accommodate intimacy and when to use them. 2.21. Sexual Health/Occupation 2.21.1. Students/practitioners should understand the foundations for sexual health and well being. 2.21.2. Students/practitioners should understand sexual development and factors that influence sexual health and safety across the lifespan. 2.21.3. Students/practitoners should understand how a new injury, diagnosis, symptoms may influence sexual health. 2.21.4. Students/Practitioners need to understand the motor, sensory, and process skills/strategies that influence engagement in sexual health. 2.21.5. Students/Practitioners need to understand how client roles, routines, habits, and rituals influence engagement in sexual health. 2.21.6. Students/practitioners should understand common supports and barriers affecting sexual health. 2.21.7. Students/practitioners should understand common concerns clients have in regards to sexual health. 2.21.8. Students/Practitioners need to know how to conduct a formal evaluation of client concerns related to sexual health, interpret results, and write measurable goals. 2.21.9. Students/practitioners need to be exposed to various types/levels of intervention when addressing sexual health. 2.21.10. Students/Practitioners need to understand the various types of aids, devices, equipment, and strategies that can be utilized to accommodate sexual health and when to use them. 2.22. Family Planning/Occupation 2.22.1. Students/practitioners should understand the foundations for family planning across the lifespan. 2.22.2. Students/practitioners should understand how a new injury, diagnosis, symptoms may influence family planning. 2.22.3. Students/practitioners should understand common supports and barriers affecting family planning. 2.22.4. Students/Practitioners need to understand the motor, sensory, and process skills/strategies that influence engagement in family planning 2.22.5. Students/Practitioners need to understand how client roles, routines, habits, and rituals influence engagement in family planning. 2.22.6. Students/practitioners should understand common concerns clients have in regards to family planning. 2.22.7. Students/Practitioners need to know how to conduct a formal evaluation of client concerns related to family planning, interpret results, and write measurable goals. ADDRESSING SEXUALITY & INTIMACY IN OCCUPATIONAL THERAPY 2.22.8. 2.22.9. 62 Students/practitioners need to be exposed to various types/levels of intervention when addressing family planning. Students/Practitioners need to understand the various types of aids, devices, equipment, and strategies that can be utilized to accommodate family planning and when to use them.  ...

... Title: Sensory Integration in Therapeutic Riding at Morning Dove Therapeutic Riding Center Sierra Lowe May, 2022 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Alissia Garabrant, Assistant Professor, Fieldwork Coordinator 2 A Capstone Project Entitled Title: Sensory Integration in Therapeutic Riding at Morning Dove Therapeutic Riding Center 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 Sierra Lowe 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 The purpose of this project was to use sensory integration (SI) through interaction with horses to see if behavior or mood changed over time in children with autism. Pre-tests were emailed to parents of qualifying riders to assess their childs behavior prior to SI activities. During the first three weeks of riding sessions, a different SI activity was integrated into their lesson plans each week. After the SI activities were implemented, post-tests were emailed to participants parents to assess parent perceived change in behavior or mood. A total of 3 parents responded to both pre and post-tests and were included in this study. The results of the study showed mood or behavior improvements after sensory integration for 2/3 participants. The results of this study were generally positive; however, the complete impact of the horse-human interaction and sensory integration is still not fully understood. 4 Introduction For individuals with a disability, therapy sessions may seem never ending with occupational, physical, and speech therapy multiple times a week. Attending these sessions may start to feel like a never ending cycle for these individuals. Therapeutic riding is a recreational outlet with the purpose of contributing positively to the cognitive, physical, emotional, and social well-being of individuals with special needs (PATH Intl., 2021). While the name implies treatment is involved during this service, this is a recreational activity where individuals work on riding skills, while incorporating life skills they may be working on in other therapy services. Morning Dove allows people of all ages and diagnoses to participate in this non-conventional recreational activity. Their mission is improving the lives of children and adults with disabilities in central Indiana through equine-assisted therapies and activities (Morning Dove Therapeutic Riding Inc., n.d.). Founded in 1998, Morning Dove is a not-for-profit organization that offers equineassisted services to the community. This organization helps a wide array of populations, including child, adolescent, and adult participants with physical, cognitive, behavioral, and/or emotional disabilities (Morning Dove Therapeutic Riding Inc., n.d.). Morning Dove is also an accredited member of the Professional Association of Therapeutic Horsemanship, International (PATH Intl.); a federally registered nonprofit that promotes equine-assisted services (EAS) for individuals with special needs. PATH Intl. is the global authority responsible for certifying instructors to help members start and maintain successful EAS programs (PATH Intl., 2021; Tan & Simmonds, 2018). Morning Doves program serves over 100 students weekly and offers a variety of riding programs that are all accredited through PATH Intl. 5 Morning Dove offers many different programs that students can participate in, including field trips, workshops, and the Lead Changes program for at-risk youth and adults. Developed in 2017, Lead Changes uses equine facilitated learning to teach the at-risk community designed for youth and addiction rehabilitation. This program is intended to build confidence, respect, positive self-esteem, and trust (Morning Dove Therapeutic Riding Inc., n.d.). Pelyva and her colleagues (2020) found that adolescents who have regular contact and a strong relationship with the horses have fewer behavior problems and stronger prosocial skills than their peers without such engagements. Frederick et al. (2015) found that at-risk youth that participates in equine assisted therapy had higher levels of hope and a decrease in depression compared to those not utilizing equine assisted therapy. Lead Changes is offered to elementary and middle schools in the greater Indianapolis area, including Marion, Boone, Hamilton, and Hendricks counties (Morning Dove Therapeutic Riding Inc., n.d.). The purpose of this project was to use sensory integration through interaction with the horses to see if behavior changes over time in children with autism. Background Therapeutic riding can be used to address many different areas: control, attention, focus, sensory management, and communication skills. Therapeutic riding provides a multisensory experience by interacting with both humans and horses and stimulates physiological, psychological, and social responses in children; that is why therapeutic riding can be so beneficial for children with ASD who typically struggle with a sensory issue (Ward et al., 2013). Hippotherapy is another type of equine assisted therapy that utilizes the movements of a horse to facilitate movements in the participant riding the horse. There are trained horse handlers that tell the horse when to go and what patterns to move in; the participant is just responsible for 6 responding to the horses movements. This type of equine assisted therapy focuses on improving posture, balance, and mobility (Mapes & Rosen, 2016). Hippotherapy is different from therapeutic riding because it is a specialist physiotherapy and rehabilitative treatment, not solely a recreational activity (Debuse et al., 2009). During the needs assessment with the site coordinator, she identified their primary population as children with autism and ADHD. She said they have a larger population of children riders than adults at the moment, but this fluctuates often; with the program being available to all people over the age of four. Morning Dove previously offered hippotherapy services through a partnership with a community hospital; however, due to budget cuts a few years ago, the program at Morning Dove was canceled. Morning Dove is aware of the great benefits occupational therapists can provide to various populations and was eager to have an occupational therapy student with them for a few months. When the site mentor was asked what she may want during the 14 week experience, she said she would appreciate help with lesson planning. Because this program is accredited by PATH, each lesson has to be individually made to benefit each student. Through this experience, the researcher hopes to use the advanced skills of program development and administration. The researcher wants to use program development to help cultivate the project. She will also use the administration skill to help make new lesson plans with the lead instructor. The site coordinator shared that Morning Dove is always open to new ideas and were really excited to have an OT student on board to provide a different therapeutic lens. There is a lot of research supporting this project because children with autism respond positively to horse-human interactions. Autism affects 1 in 68 children in the United States (Mapes & Rosen, 2016). Autism is a developmental disability that is characterized by restricted 7 and repetitive behaviors (Peters et. al., 2020). There are several comorbidities that can coincide with ASD, such as difficulties with behavioral and emotional regulation, impairment in social interaction and communication, and motor functioning that may impact their occupational performance (Lanning et al., 2014; Srinivasan et al., 2018; Wuang et al., 2010). While there is no cure for autism, treatment focuses on symptom management (Taylor et al., 2009). There are a lot of unconventional therapies that have emerged that have shown promise in improving some symptoms of autism. There are many studies that show the positive effect of animal assisted interventions because animals have the ability to positively engage with people. This can help individuals with autism counteract their social withdrawal tendencies. Animal assisted interventions with horses usually include ground work, like grooming, and also mounted riding (Borgi et al., 2016). A study conducted by Tan and Simmonds (2018) asked parents if they saw any benefits to equine-assisted therapy for their children with autism. There were four main themes discovered: (1) childs improved self-concept and emotional well-being, (2) childs improved self-regulatory ability, (3) social benefits for the child, and (4) unexpected outcomes. The main conclusion from this study was that the parents perceived equine-assisted therapy as beneficial in improving different aspects of psychosocial functioning in their children with autism (Tan & Simmonds, 2018). Another study indicated children with ASD participating in equine therapy demonstrated improvements in quality of life domains and will experience more improvement in quality of life than children in a comparison group that participated in social circles instead (Lanning et al., 2014). One pilot study conducted by Glen Cotton (2021) had a similar aim to this DCE project which was to examine the effect of hippotherapy on sensory integration in children with ASD. He found that his interventions had a significant impact on arousal, sensory discrimination, and 8 sensory modulation. His intervention resulted in an overall improvement in sensory integration of children with ASD, as well as improved adaptive responses. Cotton concluded that this is an important finding for occupational therapists because equine assisted therapy can be recommended to parents of children who would benefit from a multisensory approach (2021). With this project, the aim is to see improvements in the students behaviors to further show that therapeutic riding is beneficial to children with ASD. Hippotherapy and therapeutic riding are great examples of non-conventional activities that allow children to have fun, while not feeling like they are in therapy. Theory/Frame of Reference The model chosen to lead this DCE project is the occupational behavior model; this model has three main constructs: exploration, competence, and achievement (Cole & Tufano, 2008). Exploration is defined as new experiences that help someone develop new skills. Competence is defined as having adequate behavior to complete the activity. Achievement is defined as a level of success (Cole & Tufano, 2008). For exploration, therapeutic riding is a non-conventional recreational activity that allows people of all ages and diagnoses to explore and gain new skills. These clients have to learn the basics of grooming and caring for a horse before learning to ride the horse; therefore, there are many new skills being developed. This site also wants help with lesson planning, so as a part of this project there will be new activities added for the students to participate in, which will help them explore new skills. For competence, in order for the horses to respond positively and for the students to benefit from this activity, the students need to have positive attitudes and behaviors. This project will incorporate sensory integration to see if mood and behavior change with human-horse interactions. Once the students have the appropriate behavior needed to succeed in 9 this activity, they will be more likely to meet the demands of the activity and mastery of skills. Achievement in this setting is having a fun, positive, and beneficial experience with the horses. Whether the student is riding the horse or doing ground work (grooming, feeding, etc.) with the horse, it should be a positive experience that allows them to interact with others. Sensory Integration and Processing is the frame of reference chosen to guide the DCE project. Sensory integration can be used with children and adults with inattention, hyper or hyposensitivity to sensory stimuli, poor balance and posture control, apraxia, and cognitive processing difficulties (Cole & Tufano, 2008). The main populations at Morning Dove are children with ASD and ADHD; oftentimes these populations have sensory processing difficulties. This project will be focusing on integrating sensory stimuli while riding and taking care of the horses to see if mood and behavior improve. Sensory stimulation is largely received while doing ground work with the horses; this includes petting the horses, grooming the horses, and feeding the horses. These activities provide tactile stimuli with touching the horse and various tools for grooming. Olfactory stimulation is present with the smell of the sawdust in the stalls, the horse food, and the horse itself. Auditory stimulation is present when the horse walks and makes noise. Proprioceptive stimulation is present by moving ones body in space to groom all areas of the horse. Visual stimulation is present to see what one is doing with the horse. While riding the horse, vestibular and proprioceptive stimulation are present with feeling the motions of the horse and performing different activities on the horse. Project Project Design Based on a review of literature, studies have clarified the importance of animal-human interaction and the researcher wanted to see the impact sensory integration could have on this 10 relationship in regards to mood and behavior. The research behind horse-human interactions with individuals on the autism spectrum has already been presented; this report will now go into how the project was developed and the outcome assessment chosen to administer. First, research was conducted to find sensory integration activities that could be implemented in the 45 minute therapeutic riding sessions. Three activities were selected to incorporate into lesson plans for a week each with individuals that have a diagnosis of ASD. The activities chosen were mystery sensory boxes, beanbag balance, and Pony Express. Further details on the activities will be presented later in the report. Implementation The participants were 17 riders at Morning Dove that had a primary diagnoses of ASD. Of those participants, five were excluded because they were over the age of 18. Of the remaining 12 participants, three responded to both the pre and post-tests and were included in this study. Three sensory activities were chosen to integrate during therapeutic riding lessons. The first activity was mystery sensory boxes where the riders sense of vision was eliminated; therefore, they had to use other senses to identify the item in the boxes. The second activity implemented was a beanbag balance activity where the rider had to close their eyes and use proprioceptive input to keep the beanbag balanced; the rider was instructed to move their body through space to incorporate other skills, like bilateral hand coordination and crossing midline, while maintaining balance with the beanbag. The last activity was a Pony Express game where the riders picked an envelope out of a mailbox where there was a textured fabric (i.e. hair, scales, velvet) that had to be matched with its respective animal (i.e. horse, fish, and cow). 11 Project Outcomes A pre/post-test that were adapted forms of the Pediatric Symptom Checklist (PSC) (Figures 1&2) was used to measure outcomes. The participants parents completed the forms in regards to their childs mood and behavior. Test/retest reliability of the PSC showed a correlation coefficient with a score of 0.86 suggesting that parent ratings were stable over time (Jellinek et al., 1986). This checklist shows validity in that nearly 70% of the children that scored as PSC positive will also be identified as impaired by a physician and, conversely, 95% of the children identified as PSC negative will be identified as unimpaired. Studies have also indicated a strong internal consistency of the PSC items and a highly significant correlation between individual PSC items and positive PSC screening scores (Pediatric Symptom Checklist, n.d.). The PSC measures three factors: internalizing symptoms, attention, and externalizing symptoms. If the parent reports their childs internalizing symptom score of a 5 or higher this indicates possible anxiety or depression within the child. If the parent reports their childs attention score as 7 or more this indicated the child may have ADHD. If the parent reports their childs externalizing symptom score of 7 or higher this indicates the child may exhibit disruptive behavior. If the total score after this outcome measure is 15 or higher, this indicates that the child may have a mental health or behavioral problem. 12 Figure 1 Behavioral Health Pre-Test 13 Figure 2 Behavioral Health Post-Test Behavioral Health Post-test Before Sensory Integration Childs name:_____________________________ Who is completing the survey?:__________________ The names will be kept confidential. It is only for the researchers use to match pre/post-tests. Please circle the answer that best describes your child: 1. 2. Fidgety, unable to sit still Feels sad, unhappy 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. Daydreams too much Refuses to share Does not understand other peoples feelings Feels hopeless Has trouble paying attention Fights with other children Is down on himself or herself Blames others for his or her troubles Seems to be having less fun Doesnt listen to rules Acts as if driven by a motor Teases others Worries a lot Takes things that dont belong to him or her Distracted easily Never 0 0 Sometimes 1 1 Often 2 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Do you think therapeutic riding has improved your childs mood/behavior? Yes I Office Use A E No Where have you seen the biggest improvements in your childs behavior since starting therapeutic riding? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Would you recommend therapeutic riding to other families considering this as a non-conventional therapy? Yes No Would you recommend Morning Dove? Yes No 14 Figures 3 and 4 illustrate the pre and post-test scores. Figure 3 Behavioral Health Pre-Test Results E 1 D 4 3 2 8 C 0 3 7 5 B 0 9 A 6 7 0 2 2 4 6 Internalizing Symptoms 1 8 10 Attention 12 14 16 Externalizing Symptoms Figure 4 Behavioral Health Post-Test Results E 0 D 2 5 C 0 B 0 3 7 5 4 6 A 0 0 2 4 Internalizing Symptoms 6 8 Attention 10 12 14 Externalizing Symptoms Three parents responded to the behavioral health post-tests. One parent identified an improvement in their childs mood/behavior after the sensory integration activities; however, this participant did not report any differences through the adapted PSC. The other two parents 15 reported no improvement in their childs mood/behavior; however, the PSC scores showed improvements in the area of attention. There were many positive observations made throughout the execution of the sensory integration activities. One primary observation was the ability to overcome fear during the mystery sensory box activity; another positive interaction observed was watching the riders light up and have fun with the activities. The riders confidence grew each week as they got familiar with the horses and were able to complete the sensory activities with minimal assistance. There were many limitations that arose while implementing this project design. The primary challenge was the limited amount of time to implement the sensory integration activities. The riding sessions began on March 14th and the last day for this experience was April 15th; this allowed roughly 3 weeks to conduct the activities and receive responses from the post-tests to allow dissemination of the findings during the last week. Another limitation was enticing parents to complete the pre and post-tests to receive enough data. Emails were sent out to parents to ask for participation and followed by reminder emails in an attempt to increase participation in the study. Unfortunately, a lot of families were on spring break at the time the post-tests were distributed; therefore, I did not get a response in time. The third limitation was negativity about the sensory integration activities that was portrayed by some individuals that then made the riders feel negatively about the activity. Once the individual expressed their annoyance with the activity, the riders attitude was automatically negative before even starting the activity. Summary Children with disabilities often do not get a break from therapy, whether thats behavioral, OT, PT, speech, etc. While therapy is an extremely important part of that individuals life; it is also important to explore other opportunities, besides conventional therapies, that could 16 benefit an individual with a disability. Morning Dove Therapeutic Riding Center offers a unique ability for individuals of all ages and diagnoses to learn the skills of riding a horse, while incorporating life skills that they may be working on in therapy. Therapeutic riding also allows individuals to experience a unique, multisensory opportunity that they may not otherwise experience in their daily routines. There are different smells, sights, sounds, and textures that they get to experience at the barn and surrounded by nature. Studies show the benefits of horsehuman interaction in a variety of skills including social, emotional, psychosocial, and communication (Tan & Simmonds, 2018). While the goal of therapeutic riding is not to improve life skills, they do try to incorporate them into every session. One of the many positive results from this study is an indication that therapeutic riding can be beneficial for individuals that are seeking a multisensory, nonconventional activity. This study also suggests that more research needs to be conducted regarding sensory integration over a long span of time. The researcher found herself asking a question after looking at the results: Is it the sensory integration activities that were contributing to improvements or therapeutic riding in general? This generates another question: Is the sensory input from riding a horse enough to improve mood or behavior without added sensory focused activities? Future studies should be conducted with the purpose of teasing apart whether the sensory input from riding a horse is enough to make a change, or if incorporating sensory integration activities is truly the factor that is making a positive change in mood or behavior. Conclusion The current study adds to the literature that is continually growing regarding the impact of equine assisted activities for children with ASD. The results of this study were generally positive; however, the complete impact of the horse-human interaction and sensory integration is 17 still not fully understood. The fact that the researcher poses the above questions after the research shows that future studies are still warranted. While this study poses benefits for future research to be conducted, Morning Dove also benefitted from this project by learning how their current lesson plans can be slightly altered to target sensory integration skills. The researcher translated the research through a presentation of her findings and presenting a sensory binder that was prepared as a resource for the instructors. There are many future implications for both Morning Dove and the OT profession. Morning Dove was encouraged to explore sensory integration activities during their Barn Buddies program. This is a ground work program that requires the students to learn various important factors to taking care of a horse. It would be interesting to see if there is a big difference between groundwork and mounted work, in regards to sensory integration. It was recommened to have a future intern or student make a sensory trail or item that they have to get fully funded. With Morning Dove being a not-for-profit, they continually have to write grants to fund their programming; it could be great practice for the student to either write a grant or find someone to sponsor the sensory project they come up with. For the OT profession, this study shows that sensory integration is not a cookie cutter thing that looks the same for every person. Its important as clinicians that we stay up to date on emerging practice areas that could potentially be an option for future clients. We need to know what options are out there in order to best advocate for our clients. 18 References Borgi, M., Loliva, D., Cerino, S., Chiarotti, F., Venerosi, A., Bramini, M., Nonnis, E., Marcelli, M., Vinti, C., De Santis, C., Bisacco, F., Fagerlie, M., Frascarelli, M., & Cirulli, F. (2016). Effectiveness of a standardized equine-assisted therapy program for children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 46(1), 19. https://doi.org/10.1007/s10803-015-2530-6 Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK Incorporated. Cotton, G. (2021). Effect of hippotherapy on sensory integration among children with Autism Spectrum Disorder. American Journal of Occupational Therapy, 75(2). DOI: 10.5014/ajot.2021.75S2-RP368 Debuse, D., Gibb, C., & Chandler, C. (2009). Effects of hippotherapy on people with cerebral palsy from the users' perspective: a qualitative study. Physiotherapy Theory and Practice, 25(3), 174192. Frederick, K., Ivey Hatz, J., & Lanning, B. (2015). Not just horsing around: the impact of equine-assisted learning on levels of hope and depression in at-risk adolescents. Community Mental Health Journal, 51(7), 809-817. https://doi.org/10.1007/s10597-0159836-x Jellinek, M., Murphy, J., & Burns, B. (1986). Brief psychosocial screening in outpatient pediatric practice. Journal of Pediatrics, 109. 371-378. 19 Lanning, B., Baier, M., Ivey-Hatz, J., Krenek, N., & Tubbs, J. (2014). Effects of equine assisted activities on autism spectrum disorder. Journal of Autism and Developmental Disorders, 44(8), 18971907. https://doi.org/10.1007/s10803-014-2062-5 Mapes, A. & Rosen, L. (2016). Equine-assisted therapy for children with autism spectrum disorder: A comprehensive literature review. Review Journal of Autism and Developmental Disorders, 3. 377-386. DOI 10.1007/s40489-016-0090-0 Morning Dove Therapeutic Riding Inc. (n.d.). About us. https://morningdovetrc.org/overview/ PATH Intl. (2021). PATH International. https://www.pathintl.org/ Pediatric Symptom Checklist. (n.d.). Massachusetts General Hospital. https://www.massgeneral.org/psychiatry/treatments-and-services/pediatric-symptomchecklist Pelyva, I., Kresak R, Szovak E, & Toth AL. (2020). How equine-assisted activities affect the prosocial behavior of adolescents. International Journal of Environmental Research and Public Health, 17(8). https://doi.org/10.3390/ijerph17082967 Peters, B., Wood, W., Hepburn, S., & Bundy, A. (2020). Pilot study: Occupational therapy in an equine environement for youth with autism. OTJR: Occupation, Participation and Health, 40(3), 190-202. https://doi.org/10.1177/1539449220912723 Srinivasan, S., Cavagnino, D., & Bhat, A. (2018). Effects of equine therapy on individuals with Autism Spectrum Disorder: A systematic review. Review Journal of Autism and Developmental Disorders, 5. 156-175. https://doi.org/10.1007/s40489-018-0130-z Tan, V., & Simmonds, J. (2018). Parent perceptions of psychosocial outcomes of equine-assisted interventions for children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 48(3), 759769. https://doi.org/10.1007/s10803-017-3399-3 20 Taylor, R., Kielhofner, G., Smith, C., Butler, S., Cahill, S., Ciukaj, M., & Gehman, M. (2009). Volitional change in children with autism: a single-case design study of the impact of hippotherapy on motivation. Occupational Therapy in Mental Health, 25(2), 192200. Ward, S., Whalon, K., Rusnak, K., Wendell, K., & Paschall, N. (2013). The association between therapeutic horseback riding and the social communication and sensory reactions of children with autism. Journal of Autism and Developmental Disorders, 43(9), 21908. https://doi.org/10.1007/s10803-013-1773-3 Wuang, Y., Wang, C., Huang, M., & Su, C. (2010). The effectiveness of simulated developmental horse-riding program in children with autism. Adapted Physical Activity Quarterly: Apaq, 27(2), 11326. 21 Appendix 22 Week DCE Stage (orientation, screening/evaluation, implementation, discontinuation, dissemination) 1 Orientation (Independent Research) 2 3 Orientation Implementation Weekly Goal Objectives Revise Lit Review and review due dates throughout my capstone -Find 5 more articles for lit review -Write down all assignments in my planner -Familiarize myself with Brightspace and resources available Complete any training required Complete orientation and understand my duties and what is wanted from me during my time at Morning Dove Finalize pre/post-test choice Start sensory integration binder Review resources to build lesson plans and learn how documentation is completed at site Use pre/post tests for DCE project Tasks -Research using different search terms to find articles -Read lit review and make adjustments -Review Project Report rubric 1/14 Work with mentor on tasks given throughout the week 1/21 Brainstorm sensory integration activities to use during lesson plans Work with mentor on tasks given throughout the week Type up and organize sensory activities Help with Barn Buddies Help program supervise clients with Draft of other introduction volunteers Date complete Review weekly goals and objectives for program Write introduction 1/28 23 4 Implementation Continue working on sensory binder Finalize introduction Research new activities Help Help with supervise Barn Buddies clients with Program other volunteers Draft of background 5 Implementation Continue working on sensory binder Start lesson planning 6 Implementation Finalize background Research new activities Make individualized lesson plans from sensory integration activities Help with Barn Buddies Help Program supervise clients with Draft of other project volunteers design Finalize project design Finish Research new sensory activities binder Continue lesson planning Make individualized lesson plans from sensory integration activities Work with mentor on tasks given throughout the week 2/4 Review weekly goals and objectives for program Write background Work with mentor on tasks given throughout the week 2/11 Review past lesson plans and individuals skill levels Review weekly goals and objectives for program Write project design Work with mentor on tasks given throughout the week Review past lesson plans and individuals skill levels 2/18 24 7 Implementation Help with Help Barn Buddies supervise Program clients with other volunteers Start Review selecting sensory binder interventions to find to implement interventions for project Continue lesson planning 8 Implementation Help with Barn Buddies Program Help supervise clients with other volunteers Select Review interventions sensory binder to implement to find for project interventions Continue lesson planning 9 Implementation Make individualized lesson plans from sensory integration activities Make individualized lesson plans from sensory Help with integration Barn Buddies activities Program Help supervise clients with other volunteers Finalize Review interventions sensory binder Review weekly goals and objectives for program Work with mentor on tasks given throughout the week 2/25 Review past lesson plans and individuals skill levels Review weekly goals and objectives for program Work with mentor on tasks given throughout the week 3/4 Review past lesson plans and individuals skill levels Review weekly goals and objectives for program Work with mentor on tasks 3/11 25 to implement for project Continue lesson planning Draft of methods section 10 Implementation Administer pre-test Continue lesson planning to find interventions Make individualized lesson plans from sensory integration activities Finalize methods section Collect pretest data Make individualized lesson plans from sensory integration activities 11 Implementation Continue lesson planning Make individualized lesson plans from sensory integration activities 12 Implementation Continue lesson planning Make individualized lesson plans from sensory integration activities Work on dissemination Complete all materials sections given throughout the week Review past lesson plans and individuals skill levels Write methods section Have lead 3/18 instructor or myself administer/collect data Review past lesson plans and individuals skill levels Work with mentor on tasks given throughout the week Review past lesson plans and individuals skill levels Review past lesson plans and individuals skill levels Presentation 3/25 4/1 26 13 Discontinuation Administer post-test besides outcomes Collect posttest data Analyze data Finalize outcomes section Finalize dissemination materials 14 Dissemination Present Compare pre/post tests Rough draft of outcomes section Complete rough draft Dissemination Have lead instructor or myself administer/ collect data 4/8 Data analysis Work on outcomes Presentation Presentation 4/15  ...

... A Montessori-Based Activity Program in Occupational Therapy for Individuals with Dementia MacKenzie King April 22, 2022 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Brenda S. Howard, DHSc, OTR, FAOTA 2 Abstract As the number of individuals living with dementia rises, there is an increased need for quality dementia care. Montessori-Based Dementia Programming (MBDP) is an approach to dementia care which recognizes that people with dementia are individuals with unique needs and abilities. Previous research suggested that Montessori activities increase positive affect and engagement of individuals with dementia. Observations of ten participants living in a memory care unit took place during three regularly programmed activities and three Montessori activities to compare the amount and type of engagement. The researcher conducted Montessori activities one-on-one or in small groups with the participants. Participants displayed higher amounts of constructive engagement and less passive, self, and non-engagement during Montessori activities compared to regularly programmed activities. Participants demonstrated more pleasure and enjoyment during Montessori activities. Improvements observed in participants positive engagement and affect may give promise for implementing Montessori activities in memory care units. Keywords: Montessori, activities, dementia, engagement 3 Introduction The Hoosier Village community consists of independent living, assisted living, longterm care, rehabilitation, and memory care (Hoosier Village, n.d.). The study discussed in this paper took place in the memory care unit at Hoosier Village, known as Hickory Hall. There are currently 29 individuals living in Hickory Hall with diagnoses of Alzheimers disease, dementia, or other forms of memory loss. Hoosier Villages mission is to enrich the quality of life of older adults within an environment that addresses and supports their independence, morals, needs, and hobbies (Hoosier Village, n.d.). More specifically, the memory care units mission at Hoosier Village is to improve the quality of life of families and individuals who have memory loss (Hoosier Village, n.d.). Individuals who have dementia often live with this illness for years. While there is currently no cure for dementia, there are different patient-centered care models including MBDP. The purpose of this study was to introduce and implement MBDP in the memory care unit to facilitate constructive engagement in purposeful occupations to promote the wellbeing and quality of life of individuals with dementia. The Montessori method emphasizes the importance of ones independence, freedom to choose, and a supportive physical and social environment, which are important factors that individuals with dementia continue to value (Tak et al., 2016). The MDBP is strength-based and individualized, focusing on the individuals needs, interests, skills, and abilities (Han et al., 2016). Additionally, due to the disproportionate staff to resident ratio at many residential facilities, including Hickory Hall, activities are typically offered in large groups. When offering activities in groups, it is difficult to incorporate the interests, needs, and abilities of each individual participating in the activity. When activities do not account for individuals cognitive capacities and hobbies, the individuals are less likely to exhibit constructive engagement throughout the activity due to lack of interest or inability to complete the tasks 4 (Smith & DAmico, 2020). Meaningful and cognitively appropriate activities for individuals with dementia can help to increase positive engagement as well as reduce negative symptoms such as agitation (Orsulic-Jeras et al., 2000). In this paper, I will discuss the key principles of the Montessori method, how to determine an individuals current capacity and remaining abilities, and the role of staff in successful MBDP implementation. Ultimately, I will examine the differences in types and levels of engagement for ten individuals with dementia when participating in Montessoribased activities compared to regularly programmed activities in the memory care unit. Background There are currently more than 55 million individuals worldwide who are living with dementia (World Health Organization [WHO], 2021). By 2050, experts project there will be nearly 140 million people diagnosed with dementia (WHO, 2021). Researchers suggest psychosocial interventions and non-pharmacological interventions, such as the Montessori method, can effectively slow the progression of the disease (Oyebode & Parveen, 2019). Furthermore, psychosocial interventions improve the well-being and quality of life for individuals who have dementia (Oyebode & Parveen, 2019). In 1907, Maria Montessori developed the Montessori method for educational purposes to build on the way children naturally learn (Camp, 2010). More recently in the 1990s, Dr. Cameron Camp introduced the idea of using the Montessori method to improve dementia care (Camp, 2010). The MBDP emphasizes person-directed care where the activities, schedules, and environment are all tailored to meet the needs, interests, and preferences of the individuals with dementia (Camp, 2010). An important Montessori concept is to promote independence for individuals with dementia so that they need the least amount of help from staff during activities (Camp, 2010). The primary goal of Montessori dementia care is engagement in life (Camp, 2010). 5 Individuals with dementia face challenges after their diagnosis including internal challenges and difficulties dealing with negative perceptions or stereotypes from others. Misconceptions about persons living with dementia often leads to care providers neglecting the dignity of persons with dementia and treating them as if they are incapable of contributing in meaningful ways (Ekoh et al., 2020). One result of these negative stereotypes is that individuals living with dementia experience infantilization, which is treating someone as if they are a child despite their age and knowledge, during encounters with staff (Thompson & Fletcher, 2019). Infantilization is belittling and negatively affects a persons self-esteem and self-confidence. It is important to note that the materials used for Montessori activities as well as the activities themselves differ from those offered to children to avoid infantilization. People living with dementia reported that among the primary challenges they face when diagnosed with dementia is the feeling of losing control and the need to find meaning (Read et al., 2017). Furthermore, those living with dementia report the desire to maintain their independence and role function for as long as possible (Davison et al., 2019; Read et al., 2017). When individuals with dementia move into a residential facility, such as a memory care unit, they can become deprived of the opportunity to stay involved and complete the daily activities they once did (Morgan-Brown & Brangan, 2016). Montessori dementia care enables those living with dementia to be as independent as possible for as long as possible and to function at their highest level while improving their well-being and quality of life (Oyebode & Parveen, 2019). The Director of Operations at Hoosier Village expressed a need for more development and activity programming in the memory care unit, which guided the creation of this project. Staff believed that occupational therapy directed activities could benefit the individuals in the memory care unit since many of them do not receive therapy services. There was a need for more activities offered that are meaningful and purposeful for those 6 with dementia to increase residents constructive engagement. Additionally, there was a need for more staff training and education on dementia care. The staff needed training on how to grade or modify tasks to promote residents independence. Through observation, the researcher noted a need for more individual and small group activities that match the skills, needs, and interests of each individual with dementia. Finally, some residents in the memory care unit only participated in activities for a short period of time indicating poor engagement or inability to attend for the entirety of the activity. Current evidence suggests that nursing home residents with dementia report feeling like they have limited activity options available (Han et al., 2016). Furthermore, residents do not feel the activities offered are meaningful, which decreases their motivation to participate and engage (Han et al., 2016; Tak et al., 2015). Han et al. (2016) discussed the importance of meaningful and valuable activities to improve engagement in activities for individuals with dementia. It is important to consider each individuals abilities and match them with activities that will be satisfying (Han et al., 2016). Previous research guided this study and highlighted the importance of incorporating the residents interests and hobbies into the Montessori-based activities. The Montessori method in dementia care emphasizes the importance of residents involvement in decisions and the option for participation in purposeful activities within a supportive environment (Camp, 2010), all of which are key parts for creating opportunities for meaningful engagement. In a systematic review, Sheppard et al. (2016) concluded that using Montessori-based activities led to positive outcomes for individuals memory, attention, affect, and constructive engagement. Individuals with advanced dementia have shortened attention spans compared to those with mild or moderate dementia, which means they are unable to attend to tasks or activities that required a lot of time (Orsulic-Jeras et al., 2000). Thus, developing activities for individuals with late stages of dementia must not demand more time than the person can 7 physically attend. Furthermore, Trahan et al. (2014) discussed the importance of modifying space and social demands to improve engagement during activities. The authors also concluded that certain modification strategies can be an influential factor in improving engagement for individuals with dementia (Trahan et al., 2014). It is important to understand each persons unique physical and social needs to adapt the activity demands to meet the individuals needs. Orsulic-Jeras et al. (2000) and Giroux et al. (2010) examined the effectiveness of using the Montessori approach with people who have dementia. Orsulic-Jeras et al. (2000) assessed engagement covering four domains: constructive, passive, nonengagement, and selfengagement. Evidence shows that Montessori-based activities elicit higher levels of constructive engagement and lower levels of passive engagement and nonengagement (Orsulic-Jeras et al., 2000). In addition, Giroux et al. (2010) found that participants were more likely to actively participate in Montessori activities compared to inactivity or the regularly programmed activities provided in long-term care facilities. The researchers also found that Montessori activities are effective in satisfying dementia patients need for accomplishment (Giroux et al., 2010). The purpose for implementing Montessori-based activities is that tailored and meaningful activities should increase the individuals desire and ability to participate thereby increasing constructive engagement. While the current research details the effectiveness and benefits of Montessori dementia care and Montessori-based activities, there are holes in the literature. Previous researchers did not study or review Montessori-based activities through an occupational therapy lens using occupational therapy assessments or screening tools to properly assess individuals. Furthermore, researchers have not assessed individuals using the Allen Cognitive Level Screen (ACLS), which is a common assessment used in occupational therapy to screen functional cognition, to determine individuals remaining abilities before creating Montessori 8 activities. In this study, an occupational therapy perspective guided the MBDP. The investigator viewed the participants in this study using a holistic and person-centered approach. The investigator accounted for the life experiences, interests, needs, preferences, physical and cognitive function, and remaining abilities of each participant when developing Montessori-based activities for this study. Theory The Model of Human Occupation (MOHO) guided the development and implementation of this project. MOHO addresses the person, including their volition, performance capacity, and habituation (Cole & Tufano, 2008). These concepts guided the creation of the Montessori activities to enhance participants interest in activities. Individuals with dementia retain procedural memory and habitual tasks; therefore, considering the habits and routines of the residents was important when creating activities (Cole & Tufano, 2008). Understanding the residents performance capacities prior to creating activities ensured that the level of skill required to complete the activities matched the clients abilities. In addition, MOHO addresses occupational identity, occupational competency, occupational participation, and occupational adaptation (Cole & Tufano, 2008). As a result of the COVID-19 pandemic, residents of the memory care unit experienced occupational deprivation (K. Grissom, personal communication, March 2, 2021). The Montessori-based activity program aimed to help the residents rediscover or develop occupational identities and occupational competency. Lastly, MOHO examines an individuals environment (Cole & Tufano, 2008), which is an important aspect of my project. An emphasis on organizing and de-cluttering the environment to make it visually appealing and easy to access is an important part of encouraging participation in activities. Allens Cognitive Levels (ACL) frame of reference (FOR) guided the development of this study. Allens Cognitive Levels consists of six different levels and 52 modes of 9 performance that define a persons range of cognitive function (Cole & Tufano, 2008). The ACLS is a standardized assessment tool designed for the ACL FOR (Cole & Tufano, 2008). A persons ACLS score guides individual and group interventions or activities (Cole & Tufano, 2008). Allens Cognitive Levels focuses on the just-right challenge, which aims to match task demands to the clients current capacity for functioning (Cole & Tufano, 2008). Task demands include the materials, instructions, choices, and steps required to complete an activity (Cole & Tufano, 2008). Individuals with dementia can become irritable or frustrated if they are unable to accomplish something, which is why the just-right challenge was an important concept to emphasize in the Montessori activities. Lastly, the task environment, which is the environment in which an individual performs tasks, is an important part of Allens Cognitive Levels FOR. Adapting the task environment to be engaging and supportive for the residents was important while setting up the activities for the Montessori program. Project Design The decline of abilities, both cognitive and motor, can vary greatly among individuals who are in different stages of the disease. For this reason, individualized and tailored activities are important to meet the personal needs, interests, and abilities of individuals. For the project design, the researcher identified ten residents of the memory care unit who frequently attended regularly programmed activities and assigned them to be the participants in this study. The types of regularly programmed activities that most routinely occurred included: exercise classes, music performances, Bingo, and trivia. During the first five weeks of the study, the researcher observed and recorded the ten participants engagement in three regularly programmed activities using the Menorah Park Engagement Scale (MPES) (See Appendix B), which is a scale developed by Judge et al. (2000) to measure engagement during activities. The investigator measure participant engagement in seconds for the first ten minutes of each activity. Then, the investigator used an excel sheet to record the duration of 10 the type of engagement exhibited by each participant during the activities. One participants engagement in a single activity was equivalent to 600 seconds. Ten participants engaged in three regularly programmed activities each for a total of 1,800 seconds per person. The MPES measures four different types of engagement: constructive engagement (CE), passive engagement (PE), self-engagement (SE), and non-engagement (NE) (Judge et al., 2000). Judge et al. (2000) defined CE as motor or verbal response to the activity. PE was listening to or observing the activity (Judge et al., 2000). SE was repetitive or selfstimulating behaviors including wandering, excessive rubbing or wringing hands (Judge et al., 2000). Finally, sleeping, zoning out, or disengagement from an activity was NE (Judge et al., 2000). Researchers found that the MPES has a high content validity (Judge et al., 2000). Towards the beginning of the study, the researcher completed online educational courses to become a Certified Montessori Dementia Care Professional to become qualified to lead staff training on the Montessori approach. Based on the knowledge gained from the certification courses, the researcher created a training PowerPoint including the key components of the Montessori method, the staffs role in Montessori dementia care, information about the Allen Cognitive Level frame of reference, and how the ACLS assesses individuals cognitive function. Over the course of the study, staff in the memory care unit completed the pre-test survey (See Appendix C) designed by the researcher to capture staff members baseline knowledge on Montessori dementia care. Then, staff reviewed the Montessori dementia care PowerPoint and the researcher explained more in-depth the purpose of the Montessori approach. Finally, staff completed the post-test survey, which was identical to the pre-test survey. The purpose of the survey was to assess the staffs change in knowledge on Montessori-Based Dementia Programming after completing the training. Caregivers play a vital role in successful implementation of Montessori-based activities (Wilks et al., 2019), and it is essential that they have a proper understanding of how to lead 11 the activity sessions. The statements included on the pre and post-test survey conveyed important Montessori concepts and principles that are imperative for staff to understand to facilitate positive resident engagement during activities. Initially, leading the Montessori activities was going to be the responsibility of the certified nursing assistants (CNA); however, due to being short-staffed and very inconsistent CNA staffing in the memory care unit, the researcher led all Montessori activities. Staff education and training still occurred to increase the likelihood for sustainability of the Montessori activities. A registered occupational therapist (OTR) observed the researcher administer the ACLS to one participant to verify accuracy and competency. Then, the researcher administered the ACLS to the remaining nine participants to obtain their scores, which indicated each individuals current cognitive function and problem-solving abilities. Each participants individual ACLS score and interests guided the creation of Montessori-based activities to promote independence and success during activities. The ACLS score also suggests the amount of time a person is able to attend for, which was a key piece of information to account for when creating Montessori activities. For example, participants who are an ACL 3 can only attend to activities for up to thirty minutes in one sitting. Thus, participants with an ACL of 3 were not given activities that required more than 30 minutes to complete. The families of the residents completed a Life History Sheet to describe the residents past roles, hobbies, interests, preferred environment, and likes and dislikes. The researcher used the information gathered from the participants sheet as well as his or her score on the ACLS to develop activities that would provide purpose and that matched the participants cognitive capacity. An emphasis on the process of the activities, as opposed to the outcome, was an important focus point when creating activities. The environment was also modified to be set-up according to the Montessori principles including organized areas with activity kits 12 readily available for resident use (Appendix D), visible signage and visual cues (Appendix E), and de-cluttered spaces. The organized activity kits allowed for more accessible opportunities for residents to explore their environment and engage in activities as desired. During the second half of the study, the researcher began inviting participants to take part in Montessori-based activities that were interesting and purposeful to them. While the researcher invited participants to engage in the Montessori activities, the goal in the future is for the residents to eventually reach the point of self-initiating and spontaneously engaging in activities throughout the day. The researcher served as a support during the activity by offering guidance and cues (verbal, tactile, visual) as needed. The study used a within-subjects design where each participant served as his or her own control. The researcher observed and measured the ten participants engagement in three Montessori-based activities using the MPES for a total of another 1,800 seconds of engagement per participant. The types of Montessori-based activities the subjects participated in varied according to their past occupations, roles, and interests. However, some of the most common Montessori activities included household chores, baking, and gardening tasks. The Montessori activities took place one-on-one or in small groups based on the participants needs or preference for individual versus group activities. For the group activities, the investigator formed small groups by pairing those with comparable ACLS scores or those with similar interests and hobbies. Group activities with participants who had similar ACLS scores were more difficult to lead due to all participants needing the same level of assistance; however, the small groups made it easier to help each individual. Activities were strategically designed so that they did not exceed ten minutes for individuals who are an ACL 2, thirty minutes for those who are an ACL 3, and an hour for those who are an ACL 4. Project Outcomes 13 The investigator hypothesized that participants observed during Montessori activities would exhibit higher levels of constructive engagement and lower levels of passive, self, and non-engagement during Montessori activities compared to the regularly programmed activities. Instances of self-engagement were incredibly rare during the observation periods of activities. Only two out of ten participants displayed any occurrence of self-engagement during any regularly programmed activity and zero participants exhibited self-engagement while completing the Montessori activities. As a result, the investigator did not include selfengagement as part of the formal data analysis. The investigator used paired t-tests to analyze the participants constructive, passive, and non-engagement during regularly programmed activities and Montessori activities. Results associated with these analyses are shown in Table 1. There was a statistically significant difference found for constructive engagement (p < .05) and non-engagement (p < .05) between regularly programmed activities and Montessori activities. Passive engagement exhibited by the participants during the regularly programmed activities compared to Montessori activities approached significance but was not statistically significant (p > .05). 14 Table 1 Analyses for Participant Engagement during Regular and Montessori Activities Type of Engagement Type of Activity Mean Standard Deviation p Constructive Regular 509.1 272.5 .009 Montessori 1086.3 444.4 Regular 984 288.4 Montessori 652.5 372.7 Regular 274.2 172.97 Montessori 61.2 101.7 Passive Non .071 .015 Note. The mean and standard deviation are recorded in seconds. *Bolded items are statistically significant, p < .05 Five CNAs who worked in the memory care unit completed the MBDP training along with the pre and post-test survey, which used a 5-point Likert scale. The mean of the five staff members responses to the seven statements on the pre-test survey was 25. The mean of the post-test survey responses improved to 33. As a group, the staff demonstrated a 32% increase in knowledge and understanding of the MBDP after completing the training. One CNA shared that she believes the Montessori activity program and readily accessible activity kits will be beneficial because she said she is the only CNA working on one wing of the building majority of the time, which makes it difficult to gather and initiate activities with residents throughout the day. The researcher also collected qualitative data through observations of participants throughout the study. Prior to the beginning of the Montessori activities, participants expressed uncertainty of how to contribute by saying, What am I supposed to be doing? and I feel bad. Theres so many people working hard and I am doing nothing. Other participants wandered around looking for something to do. One participant said to another, 15 Well, lets mosey on down here and see if we can find something to do. Additionally, some participants expressed discontentment with the regularly programmed activities. One participant referred to a trivia game saying, This is like kindergarten, which suggested that the participant experienced infantilization. Another participant expressed that she does not like attending the exercise classes anymore because they have become too repetitive. Once participants began engaging in the Montessori activities, they provided positive feedback during or after participating in the Montessori activities. One participant shared, Now that was fun to make and really neat stuff to work with in response to using cookie cutters to make different objects out of homemade dough. Another participant commented, This is great. Its like we are contributing something here while building bird houses to hang in the outdoor community area. While arranging flowers, one participant said, The opportunity to do something like thisI have chills all over my body. I am really having a wonderful time. The participants responses to the Montessori activities indicated that they enjoyed themselves and experienced a sense of belonging and purpose. Summary Upon moving into residential care facilities, individuals often feel a loss of purpose, identity, and independence (Davison et al., 2019). Individuals with dementia long to continue participating in their preferred activities, fulfilling previous roles, and maintaining a sense of autonomy (Davison et al., 2019). Most memory care units offer regularly programmed activities; however, many activities do not account for the differing interests and varying levels of cognitive functioning of each resident. It is important to take an individualized approach in dementia care to meet the needs of each resident and to facilitate constructive engagement during activities. Montessori-Based Dementia Programming emphasizes the importance of understanding the unique needs, cognitive functioning, and hobbies of each resident, which allows for the creation of meaningful and suitable activity opportunities. 16 To create purposeful Montessori activities for the residents, the researcher first assessed each participant using the ACLS to determine their level of cognitive functioning. Then, the researcher collected information about the participants preferences, hobbies, interests, and past roles. The researcher created activities according to each participants ACLS score and hobbies to promote independence, motivation, and engagement. The investigator adapted the environment and task demands, as needed, to meet the needs of each participant. Overall, the Montessori approach to activities presents a useful tool for staff in memory care units to engage their residents in a meaningful and constructive manner. The findings from this study suggest that individuals with dementia exhibit greater amounts of constructive engagement and less passive engagement during Montessori activities compared to non-Montessori activities. Additionally, based on observation and participant report during and immediately after completing Montessori activities, the individuals experienced feelings of enjoyment, contribution, and purpose. Conclusion The Montessori method can be effective for actively engaging those with dementia at higher levels than regularly programmed activities. When the task demands of an activity match a persons capacity, independence completing tasks is supported and can help alleviate some of the staffs burden. It is pivotal to screen cognition using a standardized assessment tool to determine each persons functional cognition in order to create activities that meet the just-right challenge. Assessing the participants cognition demonstrated to the site that each individual retains different abilities at the different stages of dementia and a single activity is not appropriate for every individual. The investigator provided staff in the memory care unit a sheet containing each participants ACLS score and a list of activities that match the cognitive level for straightforward and easy continuation of Montessori activities. The current 17 study supports use of the Montessori method in dementia care and the process of modifying activities to meet a variety of cognitive, motor, mental, or social deficits. Continued education and advocacy for the Montessori-based activity approach is needed to advance quality person-directed and person-centered dementia care. Through an occupational therapy lens, use of the Montessori approach can allow individuals with dementia prolonged opportunities for engagement in occupations that are meaningful to them. Although the results of this study showed positive benefits through the use of Montessori activities, it is important to consider the challenge of fully integrating a MBAP where staff can conduct the activities in the face of organizational constraints. In this regard, the most critical aspect for determining sustainability of the program is whether the staff and director of the memory care unit commit to continuing the use of Montessori activities within their activity program. Additionally, the interaction between staff and residents is important for successful implementation of Montessori activities and can be the difference between a resident experiencing feelings of enjoyment or frustration. Limitations of this study include the staffing and programming restrictions at the site. Furthermore, to account for threats to validity, future researchers need to replicate these findings with larger sample sizes with increased diversity. Additionally, future researchers should implement a Montessori-based activity program in more diverse practice settings. 18 References Camp, C. J. (2010). Origins of Montessori programming for dementia. Non-pharmacological therapies in dementia, 1(2), 163-174. Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK Incorporated. Davison, T. E., Cames-Costa, V., & Clark, A. (2019). Adjusting to life in a residential aged care facility: Perspectives of people with dementia, family members and facility care staff. Journal of Clinical Nursing, 28(21-22), 3901-3913. Dementia (2021). World Health Organization. Retrieved February 2, 2022 from https://www.who.int/news-room/fact-sheets/detail/dementia Ekoh, P. C., George, E. O., Ejimakaraonye, C., & Okoye, U. O. (2020). An appraisal of public understanding of dementia across cultures. Journal of Social Work in Developing Societies, 2(1). Giroux, D., Robichaud, L., & Paradis, M. (2010). Using the Montessori approach for a clientele with cognitive impairments: A quasi-experimental design. International Journal of Aging and Human Development, 71(1), 23-41. Han, A., Radel, J., McDowd, J. M., & Sabata, D. (2016). Perspectives of people with dementia about meaningful activities: A synthesis. American Journal of Alzheimer's Disease & Other Dementias, 31(2), 115-123. Hoosier village. (n.d.). Hickory hall memory care. Retrieved January 22, 2022, from https://www.hoosiervillage.com/memory-care/ Jarrott, S. E., Gozali, T., & Gigliotti, C. M. (2008). Montessori programming for persons with dementia in the group setting: An analysis of engagement and affect. Dementia, 7(1), 109-125. Judge, K. S., Camp, C. J., & Orsulic-Jeras, S. (2000). Use of Montessori-based activities for 19 clients with dementia in adult day care: Effects on engagement. American Journal of Alzheimer's Disease, 15(1), 42-46. Morgan-Brown, M., & Brangan, J. (2016). Capturing interactive occupation and social engagement in a residential dementia and mental health setting using quantitative and narrative data. Geriatrics, 1(3), 15. Orsulic-Jeras, S., Judge, K. S., & Camp, C. J. (2000). Montessori-based activities for longterm care residents with advanced dementia: Effects on engagement and affect. The Gerontologist, 40(1), 107-111. Oyebode, J. R., & Parveen, S. (2019). Psychosocial interventions for people with dementia: An overview and commentary on recent developments. Dementia, 18(1), 8-35. Read, S. T., Toye, C., & Wynaden, D. (2017). Experiences and expectations of living with dementia: A qualitative study. Collegian, 24(5), 427-432. Sheppard, C. L., McArthur, C., & Hitzig, S. L. (2016). A systematic review of Montessoribased activities for persons with dementia. Journal of the American Medical Directors Association, 17(2), 117-122. Smith, B. C., & DAmico, M. (2020). Sensory-based interventions for adults with dementia and Alzheimers disease: A scoping review. Occupational Therapy in Health Care, 34(3), 171-201. Tak, S. H., Kedia, S., Tongumpun, T. M., & Hong, S. H. (2015). Activity engagement: Perspectives from nursing home residents with dementia. Educational Gerontology, 41(3), 182-192. Thompson, K. H., & Fletcher, P. C. (2019). Examining the perceived effects of an adult day program for individuals with dementia and their caregivers: A qualitative investigation. Clinical Nurse Specialist, 33(1), 33-42. Trahan, M. A., Kuo, J., Carlson, M. C., & Gitlin, L. N. (2014). A systematic review of 20 strategies to foster activity engagement in persons with dementia. Health Education & Behavior, 41(1_suppl), 70S-83S. Wilks, S. E., Boyd, P. A., Bates, S. M., Cain, D. S., & Geiger, J. R. (2019). Montessori-based activities among persons with late-stage dementia: Evaluation of mental and behavioral health outcomes. Dementia, 18(4), 1373-1392. 21 Appendix A Week DCE Stage (orientation, screening/evaluation, implementation, discontinuation, dissemination) 1 Researching new literature and adding to literature review Prepping for first week on-site Weekly Goal 1) Research new literature related to my DCE Objectives Meet with site mentor, other site personnel, and the site participants to 2) Add relevant introduce information to myself and literature educate them review on why I am here/what I 3) Research will do for the literature on 14 weeks creating pre and posttest Document outcome supervision measures plan and update MOU 4) Review with site capstone sites mentor vision and mission Understand site statement to environment, prepare for where to park, next week Tasks Date Complete Create a list of potential questions to ask for when I meet with people in-person at the site next week All completed by 1/14/22 22 5) Create list of questions to ask capstone site mentor on first day on-site 2 Orientation & begin screening/evaluation 1)Complete orientation 2) Complete needs assessment by the end of the week 3) Look through activity closet 4) Gather information on patients hobbies and interests 3 Screening/Evaluation 1)Complete search of literature for dress code, hours, etc. Finalize questions for Needs Assessment Perform SWOT analysis Determine needs of the site according to the director of the memory care unit Compile list of items in the activity closet for potential Montessori activities Establish and create outcome assessments Ensure that all paperwork for orientation is complete and given to site All completed by 1/21/22 Set up meetings with key personnel to complete needs assessment Finalize MOU and submit to Brightspace Review outcome assessments with site All completed 23 program evaluation measures by mid-week 2)Become a Certified Montessori Dementia Care Professional 3) Review residents Life History Sheets 4 Evaluation 1)Read Allen Cognitive Level Screening (ACLS) manual and practice administering it 2)Observe staff and residents involved in regularly used for my project mentor & faculty mentor Complete the required 7 hours of training in Montessori Dementia Care. Complete courses and test required to receive the certification Understand the broad categories of patients hobbies and interests Understand the ACLS manual to accurately understand how to administer the assessment to residents Determine how many and which residents typically attend the regularly by 1/28/22 Take notes on important information learned from Montessori Dementia Care course to include in staff training PowerPoint Create comprehensive list of interests/hobbies Make notecards with the script for administering the ACLS on them Watch videos of OTR administering the ACLS to residents Collect data at baseline by observing the participants engagement during regularly scheduled 2/4/22 2/4/22 Started by 2/4/22 24 5 Implementation programmed activities with the residents 3) Begin adding information from the Montessori Dementia Care training course into a PowerPoint for staff training 1)Finalize MontessoriBased Dementia Programming staff training PowerPoint 2) Administer pre-test survey to CNAs in memory care unit involved with leading activities 3) Educate the CNAs using the training PowerPoint programmed activities and what staff members lead the activities activities in the memory care unit Complete an educational training PowerPoint on the Montessori approach in dementia care for the CNAs in the memory care unit Finish adding 2/11/22 information to training PowerPoint Understand the staffs current knowledge on the Montessori method for dementia care Work on PowerPoint for in-service presentation next week Started by 2/4/22 Edit PowerPoint for grammar and spelling 2/11/22 Add up the total scores of all staff responses on the outcome measure Started 2/11/22 Compare pre and posttest survey results Determine 10 participants for study Started 2/11/22 2/7/22 25 4) Administer post-test survey to CNAs in memory care unit involved with leading activities 5) Continue observing residents engagement and affect during regularly programmed activities 6) Administer ACLS to participants 6 Implementation 1)Administer pre-test survey to CNAs in Determine percentage of change in staff knowledge on MontessoriBased Dementia Programming Make excel sheet for tracking participants engagement Find quiet space for participants to complete ACLS 2/11/22 Started 2/9/22 Determine the effectiveness of the staff training PowerPoint Use the Menorah Park Engagement Scale (MPES) to log type of engagement exhibited by participants in an Excel spreadsheet Determine the ACL of each participant Understand the staffs current knowledge on Add up the total scores of all staff Continued through 2/18/22 26 memory care unit involved with leading activities 2) Educate the CNAs using the training PowerPoint 3) Administer post-test survey to CNAs in memory care unit involved with leading activities 4)Observe 10 participants engagement during regularly programmed activities 5) Observe participants reactions and thoughts the Montessori method for dementia care Determine percentage of change in staff knowledge on MontessoriBased Dementia Programming Determine the effectiveness of the staff training PowerPoint Use the MPES and continue logging participants engagement in Excel Gain understanding of participants reactions or thoughts towards current responses on the outcome measure Compare pre and posttest survey results of CNAs Document type and duration of engagement for each participant during regularly programmed activities Document quotes from participants throughout the day prior to implementation of Montessori activities Continued through 2/18/22 Continued through 2/18/22 2/15/22 27 throughout the day 7 8 Implementation Implementation 6)Administer ACLS to participants 1)Create Montessori activities for participants 1)Continue developing Montessori activities for participants 2) Begin organizing the environment according to activity schedule Determine the ACL of each participant Incorporate all Montessori principles when creating the activities for participants Incorporate all Montessori principles when creating the activities for participants Create a visually Create list of each Started participants 2/25/22 preferences, likes/hobbies/interests, and ACLS score Look through activity closet to determine what materials the site already has Communicate with director of the memory care unit to request additional items Combine the participants ACLS score, interests/hobbies/likes and preferences to create Montessori activities 2/25/22 2/25/22 3/4/22 28 Montessori principles 9 Implementation 1)Begin implementing Montessori activities with the participants 10 Implementation 1)Lead Montessori activities with participants 11 Implementation 1)Finish leading Montessori activities with participants appealing, decluttered, inviting space for the participants Organize the open activity areas Print invitation sheets such as, Please help fold the laundry. Create Use the MPES to meaningful, measure engagement purposeful, and during Montessori interesting activities activities for the residents Document through use of participants Montessori comments during or principles after taking part in Montessori activities Create Use the MPES to meaningful, measure engagement purposeful, and during Montessori interesting activities activities for the residents Document through use of participants comments during or Montessori principles after taking part in Montessori activities Create Use the MPES to meaningful, measure engagement purposeful, and during Montessori interesting activities activities for Document the residents participants 3/4/22 3/4/22 Started 3/7/22 Continued 3/14/22 3/18/22 3/25/22 29 2)Administer pre-test survey to CNAs in memory care unit involved with leading activities 3) Educate the CNAs using the training PowerPoint 4) Administer post-test survey to CNAs in memory care unit involved with leading activities 12 Finish Implementation 1)Data Collection and Data Analysis through use of Montessori principles comments during or after taking part in Montessori activities Understand the staffs current knowledge on the Montessori method for dementia care Add up the total scores of all staff responses on the outcome measure Determine percentage of change in staff knowledge on MontessoriBased Dementia Programming Compare pre and posttest survey results of CNAs 3/25/22 3/25/22 Determine the effectiveness of the staff training PowerPoint Demonstrate any percentages in change 2)Secondary between pre Advanced Skill and post-test Calculate change in percentage 4/1/22 Run paired t-test in Excel 4/1/22 30 of Health Promotion and Wellness survey given to staff Determine change in participant engagement during regularly programmed activities vs. Montessori activities Determine change in participant observations before and after implementation of Montessori activities 13 Discontinuation 1)Wrap-up DCE project at site Gain expertise related to health promotion and wellness for adults 65+ Staff will feel comfortable leading Create chart 4/1/22 comparing participants comments during regularly programmed activities compared to their comments during Montessori activities Attend personal training sessions and group exercise classes 4/1/22 Assist with Rock Steady Boxing Program 4/1/22 Ask staff if they have any questions 4/8/22 31 2) Work on creating a Montessori binder to leave at site 14 Dissemination Montessoribased activities for residents in memory care unit 1)Present To promote findings of sustainability program of project implementation to director of memory care unit and director of operations 2) Provide Montessori binder to site Print the Montessori training PowerPoint, ACLS scores of participants, activity ideas and how to grade them, information about the ACL and ACLS, and research on Montessori method for dementia care Prepare and practice what to say during dissemination meetings Answer any questions from the staff Put all materials in binder and give to director of the memory care unit 4/8/22 4/15/22 4/15/22 4/14/22 32 Appendix B (Jarrott et al., 2008) 33 Appendix C PRE-TEST SURVEY Directions: Please read the statements below and respond as accurately as possible to each statement by circling the number that best describes your answer. Your answers will only be used for the purpose of the research study and will remain anonymous. After viewing the Montessori Dementia Care PowerPoint, please complete the post-test survey on the back of this paper. Likert Scale: 1= Strong disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly agree 1. I am familiar with Montessori-Based Dementia Programming. 1 2 3 4 5 2. I know the differences between regularly programmed activities in a memory care unit and Montessori-based activities. 1 2 3 4 5 3. I understand how to choose activities for residents to engage in based on their interests and hobbies. 1 2 3 4 5 4. I feel confident in my ability to adapt and grade activities to meet each individuals needs. 1 2 3 4 5 5. I feel confident with making appropriate modifications to the physical and social environment to support individuals during activities. 1 2 3 4 5 6. I understand my role as a staff member in supporting residents participation and constructive engagement throughout activities. 1 2 3 4 5 7. I feel confident that I could lead activities for residents using the Montessori principles. 1 2 3 4 5 Thank you for your time and feedback! POST-TEST SURVEY 34 Directions: Please read the statements below and respond as accurately as possible to each statement by circling the number that best describes your answer. Your answers will only be used for the purpose of the research study and will remain anonymous. Likert Scale: 1= Strong disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly agree 1. I am familiar with Montessori-Based Dementia Programming. 1 2 3 4 5 2. I know the differences between regularly programmed activities in a memory care unit and Montessori-based activities. 1 2 3 4 5 3. I understand how to choose activities for residents to engage in based on their interests and hobbies. 1 2 3 4 5 4. I feel confident in my ability to adapt and grade activities to meet each individuals needs. 1 2 3 4 5 5. I feel confident with making appropriate modifications to the physical and social environment to support individuals during activities. 1 2 3 4 5 6. I understand my role as a staff member in supporting residents participation and constructive engagement throughout activities. 1 2 3 4 5 7. I feel confident that I could lead activities for residents using the Montessori principles. 1 2 3 4 5 Thank you for your time and feedback! Appendix D 35 Appendix E 36  ...

... 1 Program Evaluation in the Trauma Recovery Program at the VA Lauren Kelley May 2022 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Dr. Christine Kroll, OTD, MS, OTR, FAOTA 2 A Capstone Project Entitled Program Evaluation in the Trauma Recovery Program at the VA 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 Lauren Kelley 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 3 Abstract Background With limited literature on the role of OT in PTSD treatments it is important to continue to advocate for an interdisciplinary place for OT. Project Design A program evaluation was developed for the Trauma Recovery Program to determine areas of improvement. Retrospective data was also collected using documentation. Project Outcomes There was a total of 65 veterans included in the data collection. It was found that session three has the highest frequency of incomplete homework and no shows, and session two has the highest dropouts. There were eight total areas of improvement found from observations: exit survey, measurement-based care tool, inconsistent documentation, limited homework details in documentation, secure messaging, seating in waiting areas, Prolonged Exposure and Cognitive Processing Therapy Manuals, and scheduling issues. Conclusion Program evaluation of the Trauma Recovery Program has provided resources and data to improve the clinics future participation and overall veteran and staff satisfaction. 4 Program Evaluation in the Trauma Recovery Program at the VA The Trauma Recovery Program (TRP) is a specialty program within the Mental Health Clinic (MHC) at the Richard L. Roudebush VA in Indianapolis. The TRPs primary focus is military-based trauma, where the goal is to reduce PTSD symptoms and increase quality of life (Veterans Affairs Medical Center: Trauma Recovery Program, 2019). The TRP team is staffed with four clinical psychologists who only see patients through the TRP. There are three treatment options: Cognitive Processing Therapy (CPT), Prolonged Exposure (PE), and Written Exposure Therapy (WET). All treatment option are evidence-based practices, and each treatment is offered in individual and group settings as well as face-to-face and virtual. For this capstone project, I focused on individual treatment sessions for data collection, including face-to-face and virtual. My capstone project focuses on program evaluation of the TRP. I collected data from patient charts and discussed areas of improvement with TRP staff. Along with completing a program evaluation, I completed a Prospective Role of Occupational Therapy (OT) in PTSD Treatment binder to advocate for OT treatment in the TRP team. Program evaluation of the TRP is important because we need to look within the program to find areas of improvement to increase veteran intrinsic motivation to carry over to program completion. According to Hoge et al. (2014) one-third of veterans drop out of treatment by the third or fourth session. Advocating for OT to be a part of the TRP team is also advocating for OT to be a part of the overall health team that the individuals receive when diagnosed with PTSD (Edgelow et al., 2019). The presence of OT within the care-plan would assist the client-centered care of those treated for PTSD. 5 Background A brief needs assessment was given to the staff roughly a year before the capstone project start date to allow for project development. After asking the clinical psychologists what their biggest concerns were for the program, it came down to two main focuses. Overall, the first concern was completing the TRP program and the second was homework completion. The TRP team wants to increase the number of veterans that continue to complete the TRP protocol and treatments. One way to increase the completion of the program is to increase the completion of the homework assignments along with the treatments. Along with increasing veteran participation, the TRP staff was excited to work with an OT student since they have never worked with an occupational therapy practitioner (OTP) before. It is estimated that half of US veterans who have served in Iraq or Afghanistan show symptoms of PTSD (Campbell, Ryan, Wright, Devore, & Hoge, 2016). According to a study done in 2014 by Hoge et al., veterans diagnosed with PTSD who received evidence-based treatment, 40.8% received three or fewer treatments before leaving the program and 41% received eight or more treatments. Eight or more treatments is the minimally adequate quality of care to receive for the evidence-based PTSD treatment (Hoge et al., 2014). This study and the focus of this program evaluation is to look at what we can improve within the program that will increase program completion to give a better quality of care to the veterans. In many cases, OTs are not included in the interdisciplinary teams that treat individuals diagnosed with PTSD. In a scoping review by Edgelow et al. (2019), the researchers looked at how OT can address PTSD in a clinical setting, specifically focused on individuals with combatrelated trauma. From the 50 articles looked at, the most frequently used OT assessment was the Canadian Occupation Performance Measure (COPM). It was discussed how the COPM allows 6 the clients to understand how their trauma impacts different areas of their lives as well as allows them to prioritize their goals for treatment. The scarcity of literature on the role of OT and the lack of evidence for OT programs could affect the implementation and awareness of OT in this field of practice. Kerr et al. (2020) built off of the 2019 Edgelow et al. article to highlight military personal-focused articles and the lack thereof. The researchers found that most articles do not justify the efficacy of OT treatment plans when related to PTSD. Interventions utilized during this research to complement traumafocused treatment and support re-engagement of everyday life included early intervention programs, creating therapeutic environments, and assisting with the transition to civilian life (Kerr et al., 2020). Therefore, the researchers are supporting OT in the treatment process for PTSD and focus on that treatment with military veterans while also calling for more training and focusing on trauma-informed care for OTP. Workplace mental health (WMH) is an expanding area that OTP can practice. Occupational therapists can play a significant role in WMH by determining risk factors and providing appropriate interventions to promote mental health and workplace safety. However, one finding that Moll et al. (2018) had was limited awareness of OT and buy-in from stakeholders. From the study, there were three major issues: defining the role of occupational therapy in WMH, training, and resources required to build the OTs competence in this area, and advocating for OTs in WMH (Moll et al.,2013 & Ajila & Adetayo, 2013). Occupational health psychology focuses on the well-being of people in the workplace (Kinnunen-Amoroso & Liira, 2016). According to Beehr (2019), the use of mindfulness practices could be used as an intervention for an individual to help them be more resilient towards a poorly designed job, work environment, or both. Beehr (2019) also mentions that 7 many studies looking at workplace well-being look at different outcomes and different interventions, so it is hard to summarize for one generalized intervention. Between August 2006 and November 2010, the RAND Coorporation/ Altarum team conducted a study that evaluates the mental health care system through the US Department of Veterans Affairs (VA) (Watkins et al., 2011). The evaluation focused on the quality of care being delivered to individuals diagnosed with schizophrenia, bipolar disorder, PTSD, major depressive disorder, and/or substance abuse (Watkins et al.). The researchers used a structure-processoutcomes framework to use as a measure for their quality of care. The structure of care looked at the staffing level, how many patients can be served, hours of operation, provider workload, and availability of evidence-based practice. The care process was focused on the extent of evidence, frequency and timing of services, and appropriate monitoring for side effects. The care outcome was focused on patient satisfaction, quality of life, functions status, and cost (Watkins et al., 2011). The researchers included diagnosis and assessment, treatment, chronic disease management, and rehabilitation goals 5-diagnoses. While this program review is very extensive and lasted many years, the researchers designed the study to serve as a model for evaluating other mental health systems (Watkins et al., 2011). They found that the significant gaps were in areas of evidence-based practice. Based on this program evaluation, there were many areas of improvement specific to the mental health department of the VA. While this was completed in 2010, the TRP is a specialty clinic in the MHC, and it has been 12 years since this program evaluation. There is a need to reevaluate the quality of care delivered to the veterans to assess the client-centered and evidence-based approach needed to provide a high quality of mental health care. 8 While many researchers like Hoge et al., (2014) have looked at Veterans' participation in evidence-based PTSD treatments, they did not look at the completion of veterans enrolled in a program that strictly focused on administering of those treatments. Instead, researchers like Watkins et al. (2011) focused on the big picture of the MHC at the VA over a longer period. This capstone project focuses on two parts. The first part is a smaller program evaluation on the Trauma Recovery Program whose main priority is to deliver quality PTSD treatment to veterans. The second part of the capstone project is to advocate for OT within this mental health setting by creating a Perspective Role of OT in PTSD Treatment binder that includes possible assessment tools, interventions, a case study, and rationales to support each section. Theory The Kawa Model focuses on the interconnectedness of the client, their environment, life circumstances, assets, and liabilities (Lape & Scaide, 2017). Function is defined as the client reaching harmony within relationships, belonging, and interdependence. For an individual to reach harmony is unique to each person and culture (Lape & Scaide, 2017). For my DCE project, I evaluated how the Trauma Recovery Program staff are perform as a team and what is blocking their ability to treat their patients most effectively. Using the Kawa Model to guide my DCE project will help define what obstacles are blocking the flow of practice in this department. I can define the obstacles by using the metaphor of rocks, driftwood, and the walls and floor. According to Lape and Scaife (2017), the Kawa model can help with team building and collaboration among interprofessional groups as well as correlate to job satisfaction and quality of care. This model guides my DCE project to identify barriers to quality care, encourage teambuilding, and help advocate for OT through interdisciplinary teams. 9 The Canadian Model of Occupational Performance (CMOP) focuses on how the clients occupational performance evolves with the interactions among person, environment, and occupation (Cole & Tufano, 2008). One of the main focuses was to improve the perspective of the current TRP team members and how they interact with each other, and how their environment can impact their performance as health care professionals. Function under the CMOP is defined as a person-environment-occupation balance (Cole & Tufano, 2008). If there is a change or absence of balance between factors, occupational performance can be affected. I evaluated the TRP and the team members performance, and used the teams needs to motivate change in the program. Motivation to change under the CMOP is only done intrinsically and is facilitated through the clients participation in identifying goals and priorities (Cole & Tufano, 2008). Working closely with the team members was the best strategy to facilitate change since they create the goals for change. Project Design The capstone project began with delivering a needs assessment to each clinical psychologist on the Trauma Recovery Program (TRP) team. The individual needs assessments provided a better understanding of what each individual therapist wanted out of the program evaluation and what they thought needed improvement within their program. The needs assessment uncovered valuable information on how the program worked and how the therapist functioned independently and as a unit. I created a chart that included each therapists wanted improvements, common veteran complaints, and a section for additional resources therapists would want to add to the program from the needs assessment. From the chart, I compared what the therapist said and created a 10 weekly plan to work on these areas of concern. While I could not address every concern, I created a written recommendation and provided resources to support the recommended solutions. I used the Center for Diseases Control and Prevention (CDC) framework for program evaluation in public health as a guide to building the base for my program evaluation. The CDC steps to program evaluation include engaging stakeholders, describing the program, focusing the evaluation design, gathering credible evidence, justifying a conclusion, and ensuring the use and sharing of the lessons learned (Milstein & Wetterhall, 1999). I also looked at the Quality Enhancement Research Initiative (QUERI) program at the Veteran Health Administration as a guide for building my program evaluation. The QUERI innovative worked to achieve best clinical practices (Stetler et al., 2006). The researchers involved in the project were asked to collect data on the actual degree of less-than-best practice, determinants of current practice, potential barriers, and facilitators to practice change and implement the adoption strategy and strategy feasibility, including the perceived utility of the project (Stetler et al., 2006). During the first ten weeks of the 14-week rotation, I collected retrospective data from documentation from the TRP. I looked at veterans who have participated in the TRP program since January 2020. I collected information on start date, end date, type of treatment, total sessions completed, total no shows, homeworks not completed, reasons for not completing, sessions that reported treatment was getting hard and reason the why, and session treatments that were reported as getting easier. I also collected information for veterans who did not complete their treatment plans and any information they gave for not completing the program. Throughout the rotation, I created a binder for resources that supported the role of an OTP in the TRP. In addition, I used the treatment plans and triage notes from TRP current case 11 load to base the interventions on to make sure they were client-centered around this specific population. Barriers to the project included limited interaction with veterans, limited access to resources as a student, and delayed communication between departments at the VA. Since my site mentor was a clinical psychologist and I am the only OT student on site, I was not permitted to interact with veterans directly. According to VA rules, a supervisor must be trained in the students area of education for direct client access. Another barrier to this project includes the limited sample size used for the final data analysis. Data was lost due to limited time for analyses when going back through for more detailed information. Halfway during the data collection, the data collection process was restarted to collect more specific and detailed information from the retrospective chart reviews. Project Outcomes Retrospective data was collected between February 2019 to March 2022 with most veterans having a duration of treatment of 6-months to 1-year. There is a total of 65 veterans that have been included in the data collection. The criteria included was that the veteran was seen by one of the four therapists currently practicing and had to have completed at least one Individual Evidence Based Psychotherapy. By completing one evidence-based session this means they participated in one session of PE, CPT, or WET. When completing data analysis, veterans who participated in WET were excluded from homework analysis due to the WET intervention not involving homework assignments. This only decreased the total veteran number to 62 instead of the original 65. From Figure 1 you can see that session three had the most amount of no shows out of all the session. From Figure 2 you can see that session two had the highest number of dropouts. However, there was an error when calculating the dropout session and when recording 12 dropout sessions, the session recorded as the dropout session is the veterans last attended session. This error was made during data collection. From Figure 3 you can see that most of the time, veterans are completing their homework. Only two sessions have the highest frequency of incomplete homework: session 1B and session 5B. Even though homework is being completed most of the time, data was analyzed to look at what sessions it frequently was not being done. The session with the highest frequency of incomplete homework was session three with eight veterans not completing their homework and nine veterans partially completing their homework. Followed by session two with six veterans not completing their homework and three veterans partially completing their homework. There are eight areas of improvement based on observation, documentation, and data analysis that may increase veteran participation and staff satisfaction in the Trauma Recovery Program (TRP). The first area of improvement is an addition of an Exit Survey/Ending Treatment Survey. The TRP does not currently have any type of survey/documentation system that records reasons why veterans are leaving the program. The survey that was created were questions taken from an article by Hoge et al. (2014) that was used by the VA as evidence for new implementation of WET. Since this study is used as a reliable source in the training of the VA psychologist in WET, the site mentor and OTS discussed that these questions were appropriate to ask veterans. The second area of improvement found was the use of the measurement-based care tool PTSD Checklist 5 (PCL-5). During the rotation, the team was notified about the decreased use of the PCL-5 over the past year by the MHC at the VA. Due to the decreased use, the team had to create an implementation plan to incorporate the PCL-5 into more sessions. The site mentor used information gathered from Hoge et al. (2014) and early data from the TRPs own 13 documentation to implement a PCL-5 protocol to increase the use of the measurement-based care tool throughout treatment. The third problem area is inconsistent documentation between each therapist. Every therapist has their own style of documentation, however there is a large difference between the four therapist styles when it comes to the narrative portion of the documentation. There also seems to be a difference in documentation detailing depending on the time of day it was completed, with documents completed later in the day having fewer narrative sections than ones completed in the morning. The recommendation is to keep consistent documentation throughout all veterans. This may be difficult due to the large caseload the therapists hold and limited breaks between sessions the therapists receive which lead to burnout towards the end of the day. A solution to this problem that may not be easily solved is a lower caseload or scheduled breaks between sessions to reduce burnout. The fourth area of improvement is to include more details about homework within the documentation. Since the homework is a crucial part of the program, the suggested change to documentation is to note how many worksheets are being completed. This change in documentation may allow the therapist to track which assignments are being pushed to the side as well as track veteran engagement in the program. The fifth area of improvement is the secure messaging communication system. One of the concerns that was brought up was that veterans were unhappy with the communication between veterans and the TRP. Secure messaging is what the VA uses to keep medical information secure while still using a form of instant messaging. The secure message is delivered to the MHC which is sifted by a front desk worker and then sent to the appropriate staff member. The suggestion to the team was to create a TRP specific secure message site so that it could be more 14 direct and hopefully cut down on response times for the veterans. The site mentor does not believe implementing this will be the best course of action since many veterans who have graduated the program like to reach back out to the therapist. Creating a separate TRP secure messaging site would be a barrier to those who have graduated the program. However, the site mentor will keep the idea in mind for the future, if the problem of communication between veterans and psychologists continues to be an issue. The sixth improvement area is the seating in the waiting rooms. This information was not collected during a survey since the VA did not allow official documents to be handed out. However, from observations when sitting next to the check-out area, most veterans who sat in the chairs complained about how low they were and how difficult it was to sit and stand from them. After looking at the seating in both waiting areas, the chairs did not have armrest to assist with standing, the cushions were soft and difficult to stand from, and the chairs were low to the ground. This made it very difficult for the older veterans with mobility issues to stand from the chair as well as the veterans with combat related disabilities. The suggestion was to switch out the chairs for ones that were slightly higher and ones that had armrest to make it easier for transferring in and out of. The seventh improvement area was the PE and CPT manuals. The PE treatment did not have a book of worksheets for veterans. During the rotation a PE manual was created so the veterans had everything they needed at the beginning of treatment. The team already utilized a standardized CPT manual, however the veterans and psychologists had issues with the organization of the documents. The CPT was organized for better use in hard copy and online use as well as analyzed for health literacy issues. 15 The eighth and final improvement area is the scheduling issues the team is having. The VA is currently using front desk workers to schedule veterans for the psychologist on the TRP team and the rest of the MHC. Previously, the TRP had their own scheduler that worked just with the four psychologist and understood their schedules. Now there are over 40 social workers, psychologists, nurse practitioners, and pharmacists working in the MHC going through the same 2-4 front desk workers during the day. The recommendation is for the team to return to having their own scheduler to improve productivity of the clinic and decrease scheduling errors. Summary It was important to complete a program evaluation of the TRP to look at the areas of improvement within the program to increase carry over of intrinsic motivation of the veterans that may increase program completion in the future. The needs assessment uncovered valuable information on how the program worked and how the therapist functioned independently and as a unit. Throughout the program evaluation there were eight areas of improvement that were found: Exit Survey, Measurement-based care tool (PCL-5), Inconsistent Documentation, Homework details in documentation, Secure Messaging, Seating in waiting areas, PE and CPT Manuals, and Scheduling Issues. By advocating for OT to be a part of the TRP team, this is also advocating to OT to be a part of the overall health team for individuals with PTSD. An OT can be an important role in an interdisciplinary team for individuals diagnosed with PTSD (Edgelow et al, 2019 & Grifin et al., 2020). The limited literature available on the role of OT and the lack of evidence for OT programs could affect the implementation and awareness of OT in this field of practice. 16 From the data, the TRP team can gather information about sessions and use this information to better prepare veterans for their trauma treatment in hopes to increase overall program participation and completion. Session three had the most amount of no shows out of all the session and session two had the highest number of dropouts. The session with the highest frequency of incomplete homework was session three with eight veterans not completing their homework and nine veterans partially completing their homework. Conclusion The TRP team at the VA will use the data and apply it to how they introduce their treatment options to their veterans during orientation. What the team has learned from the data collected is that during session three, most veterans struggle with the content in the interventions. The team has discussed tell the veterans that there will be a time where they will be challenged however, once they make it through it gets easier. The team has also discussed adapting their documentation to add more details pertaining to homework completion. The team discussed that adding how many homework sheets the veterans completed will add an additional level of accountability as well as support for therapist if in the future they deem the veteran needs to be dropped from the program and is not participating in treatment. They will have in their documentation how much or how little homework has been completed. This program evaluation has given the TRP staff resources to better improve their clinics participation and overall client and staff satisfaction for the future. Due to the exposure to OT, the MHC has considered adding an occupational therapist to the staff and expand their interdisciplinary team. 17 Figure 1 No Shows by Therapy Graph Figure 2 Drop Out Session Graph 18 Figure 3 Highest Frequency of Reported Homework for Each Session (by key value) Highest Frequency of Reported Homework for Each Session 19 References Ajila, C. O., & Adetayo, H. O. (2013). Workplace counselling: implications for enhanced productivity: ethical issues in clinical psychology. IFE PsychologIA: An International Journal, 21(3), 197-210. Beehr, T. A. (2019). Interventions in occupational health psychology. Journal of occupational health psychology, 24(1), 1. Campbell, M. S., Ryan, M., Wright, D., Devore, M. D., & Hoge, C. W. (2016). Postdeployment PTSD and addictive combat attachment behaviors in US military service members. American Journal of Psychiatry, 173(12), 1171-1176. Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK Incorporated. Edgelow, M. M., MacPherson, M. M., Arnaly, F., Tam-Seto, L., & Cramm, H. A. (2019). Occupational therapy and posttraumatic stress disorder: A scoping review. Canadian Journal of Occupational Therapy, 86(2), 148-157. Griffin, G., Bicker, S., Zammit, K., & Patterson, S. (2020). Establishing an occupational therapy assessment clinic in a public mental health service: A pragmatic mixed-methods evaluation of feasibility, utilisation, and impact. Australian occupational therapy journal, 67(4), 350-359. Hoge, C. W., Grossman, S. H., Auchterlonie, J. L., Riviere, L. A., Milliken, C. S., & Wilk, J. E. (2014). PTSD treatment for soldiers after combat deployment: Low utilization of mental health care and reasons for dropout. Psychiatric services, 65(8), 997-1004. 20 Kerr, N. C., Ashby, S., Gerardi, S. M., & Lane, S. J. (2020). Occupational therapy for military personnel and military veterans experiencing posttraumatic stress disorder: A scoping review. Australian Occupational Therapy Journal, 67(5), 479-497. Kinnunen-Amoroso, M., & Liira, J. (2016). Work-related stress management between workplace and occupational health care. Work, 54(3), 507-515. Milstein, B., & Wetterhall, S. F. (1999). Framework for program evaluation in public health. Center for Disease Control and Prevention, 48(No. RR-11) Moll, S. E., Heino, C. M., LeBlanc, A. H., Beck, L. B., & Kalef, L. M. (2018). Workplace mental health: Current practice and support needs of Ontario occupational therapists. Canadian Journal of Occupational Therapy, 85(5), 408-417. Lape, J. E., & Scaife, B. D. (2017). Use of the KAWA model for teambuilding with rehabilitative professionals: An exploratory study. Internet Journal of Allied Health Sciences and Practice, 15(1), 10. Stetler, C. B., Legro, M. W., Wallace, C. M., Bowman, C., Guihan, M., Hagedorn, H., ... & Smith, J. L. (2006). The role of formative evaluation in implementation research and the QUERI experience. Journal of general internal medicine, 21(2), S1-S8. Veterans Affairs Medical Center: Trauma Recovery Program, (2019). TRP Orientation. U.S. Department of Veterans Affairs. Retrieved from: Orientation Booklet 8.2019.pdf Watkins, K. E., Pincus, H. A., Smith, B., Paddock, S. M., Mannle Jr, T. E., Woodroffe, A., & Call, C. (2011). Veterans Health Administration mental health program evaluation. Santa Monica, CA: RAND Corporation. TR-956-VHA. As of November, 19, 2012. 21 Appendix A Week DCE Stage 1 Orientation 2 Weekly Goal 1) Complete orientation by the end of the week Screening/Evaluatio n 2) Complete 2/4 Needs Assessment by end of the week Screening/Evaluatio n 1) Complete literature search of time waste and program evaluation 2) Identify use of 5S and PDCA Cycle in work environment 3 Screening/Evaluatio n 3) Complete 4/4 Needs Assessments and Summarize 1) organize data about pts homework assignments 2) organize data about office/environmenta l organization 3) create exit survey for pts to complete for future use 4 Implementation 1) implement using PDCA Cycle 2) MOU Goal A: Client will identify 3 areas of improvement in the current homework Objectives 1) meet with site mentor and other staff members to introduce myself and my project 2) Document supervision plan, meetings, and updated MOU with site mentor 3) Finalize/reevaluat e needs assessment 1) establish outcome assessment 2) complete waste assessment 3) gather current EBP articles being use in the program 1) gather information on homework assignments, program dropout rates, and other problem areas 2) gather information about resources available to pts. 3) review exit survey with site mentor 1) Use Plan/Do: implement findings from evaluation 2) gather information on homework Tasks 1) Set up meetings with TRP staff 2) Create general questions for each individual/meeting 3) Finalize MOU with updated signatures 4) Determine weekly/frequent meeting times to meet with staff members 1) review assessment with site mentor and staff 2) review 5S and PDCA Cycle examples with TRP team members 3) create meetings with staff members 1)continue to meet with TRP team 2) create excel files to collect any existing data and collect new data 3) organize existing EBP 4) organize existing resources for pts to increase participation/performanc e 1)continue to meet with TRP team Date complete 22 curriculum. 3) MOU Goal C: Student will complete one case study of potential client to demonstrate the need for OT. assignments, program dropout rates, and other problem areas 3) continue working on OT binder 4) MOU Goal E: Student will provide 3 modifications to treatment plans to improve program participation. 5 Implementation 5)MOU Goal G: Student will identify 3 organizational strategies to improve administrative organization. 1) implement using PDCA Cycle 2) find interventions to add to OT binder that connect to existing TRP treatment (CPT) 6 Implementation 1) implement using PDCA Cycle 2) find interventions to add to OT binder that connect to existing TRP treatment (PE) 1) Use Plan/Do: implement findings from evaluation 1)continue to meet with TRP team 2) gather information on homework assignments, program dropout rates, and other problem areas 3) continue working on OT binder 1) Use Plan/Do: implement findings from evaluation 2) gather information on homework assignments, program dropout rates, and other problem areas 3) continue working on OT binder 1)continue to meet with TRP team 23 7 Implementation 1) implement PDCA Cycle 1) Use Plan/Do: implement findings from evaluation 1)continue to meet with TRP team 2) gather information on homework assignments, program dropout rates, and other problem areas 8 Implementation 1) implement PDCA Cycle 2) MOU Goal B: Clients will implement 3 new homework techniques to increase homework completion in the TRP. 3) MOU Goal D: Student will have 15 resources directly related to OT intervention in mental health to advocate for OT in this setting. 3) continue working on OT binder 1) Use Check: to see how the change worked 1)continue to meet with TRP team 2) gather information on homework assignments, program dropout rates, and other problem areas 3) continue working on OT binder 4) MOU Goal F: Client will apply at least 1 modification to treatment curriculum to improve program participation. 9 Implementation 5) MOU Goal H: Student will implement 2 organizational strategies to improve administrative organization. 1) implement using PDCA Cycle 1) Use Check: to see how the change worked 1)continue to meet with TRP team 24 2) gather information on homework assignments, program dropout rates, and other problem areas 10 Implementation 1) implement using PDCA Cycle 3) continue working on OT binder 1) Use Check: to see how the change worked 1)continue to meet with TRP team 2) gather information on homework assignments, program dropout rates, and other problem areas 11 Implementation 1) implement using PDCA Cycle 3) continue working on OT binder 1) Use Check: to see how the change worked 1)continue to meet with TRP team 2) gather information on homework assignments, program dropout rates, and other problem areas 12 Discontinuation 1) Gather information on satisfaction of changes and OT intervention 3) continue working on OT binder 1) Use Check: to see how the change worked 2) gather information on homework assignments, program dropout rates, and other problem areas 3) continue working on OT 1)continue to meet with TRP team 25 13 14 Discontinuation Dissemination 1) complete all documentation and organize in corresponding binders Present to TRP Team binder 1) one binder for program evaluation and administrative organization 2) one binder for OT advocacy and OT case study 1) print needed documentation 2)continue to meet with TRP team  ...

... Sensory Friendly Training Program and Resources for Special Need Ministry Volunteers Skyla Jones May 2022 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Dr. Alissia Garabrant, OTR, OTD Abstract Efforts have been made to ensure that individuals with disabilities are able to participate in various activities in multiple contexts to enhance their quality of life. Research suggests that children with disabilities and their families value congregational life just as much as children without disabilities; however, limited attention is given to the participation and presence of children with disabilities in faith-based communities. A common barrier limiting participation in faith-based communities is the congregations lack of knowledge and training. This project focused on the development of a sensory-friendly training program and resources for special needs ministry volunteers. The training provided education on sensory-integration-based strategies to support and supplement sensory rooms at a multi-site church. The results of this study indicate the benefits of efficient education and training to help volunteers support children and youth with disabilities so they can successfully engage in spiritual and religious activities. 3 Introduction Children with disabilities and other varying needs often have limited support and encounter barriers that hinder their participation in meaningful activities related to spirituality and religion. This doctoral capstone project took place at Church of the Highlands, a multi-site church based in the state of Alabama, specifically with Highlands Haven, a special needs ministry. Highlands Haven special needs ministry "exists to share the love of Christ by assisting individuals needing special accommodations and their families to become full participants and contributors in the body of Christ" (Church of the Highlands, n.d.). Highlands Haven has various resources such as a sensory room, to help support this populations successful participation in congregational activities. In spite of the support available through this ministry, Highlands Haven volunteers have limited knowledge about how to utilize their resources in a proper manner to meet the needs of children in Haven. This project focused on the development of a sensory-friendly training program within a faith-based community. Utilizing sensory integrationbased practices, a sensory-friendly training program and resources for volunteers in special needs ministry were created. The training focused on providing insight into sustaining and supplementing sensory rooms. Training materials consisted of curriculum development and visuals that educate on sensory processing disorder, the purpose of a sensory room, and appropriate sensory integration-based strategies volunteers can use in the sensory room. This project aimed to help Highlands Haven volunteers gain a better understanding of the sensory room, by identifying sensory strategies to meet the sensory needs of children in Haven and maximize usage of the sensory room that allows children and families access to ministry, worship, and fellowship with one another. 4 Background For over several decades, significant efforts have been made to ensure that individuals with disabilities have the opportunities, supports, and relationships in place that allow them to participate in all aspects of life fully. Advocates, policymakers, and researchers have emphasized the inclusion of individuals with disabilities in school, work, residential, and community settings. Awareness within these settings has garnered much attention. However, less is known about the supports in place for children with disabilities in faith-based communities. Religious involvement is just as significant to children with disabilities and their families as to children without disabilities (Carter et al., 2016, Carter, 2016, Liu et al., 2014, Whitehead, 2018). Active participation in religious and spiritual activities is associated with improved mental, emotional, and physical health, higher self-esteem, and better-quality interpersonal relationships (Ault et al., 2013a, Ault et al., 2013b, Whitehead, 2018). With the noted value spiritual and religious expression has on the lives of children with disabilities, there should be opportunities and supports in place to promote participation in faith-based communities. Studies suggest there is a significant difference in religious service attendance between children with disabilities and children without disabilities (Whitehead, 2018, Ault et al., 2013a, Carter & Boehm, 2019); this is unfortunate as the prevalence of children with developmental disabilities and chronic conditions increases (Richie, 2015). According to the Center for Disease Control and Prevention (CDC, 2021), one in six (17%) children aged three through seventeen years is diagnosed with one or more developmental disabilities. A principal barrier identified that contributes to the absence of children with disabilities in faith-based communities is the lack of knowledge about disability and how to address their needs. This barrier can lead to faith community members feeling ill-prepared to lead such efforts without guidance. Studies have 5 shown those unfamiliar or unknowledgeable about disabilities feel uncomfortable when interacting with an individual with a disability. (Carter et al., 2016, Carter 2020, Ault et al., 2013a, Lindsay & Cancelliere 2018,). Provision of education and training on disabilities is an indicated need. Training by those with disability-related experiences or experts with knowledge in targeted areas such as special educators and occupational therapists would be beneficial. Equipping faith community members with this knowledge will improve support for this population. Future implications in the literature consider resolutions that reduce knowledge and attitudinal barriers. Several studies suggest attitudinal and educational changes involve faith leaders receiving frequent disability training and obtaining access to educational resources that address disability-related issues such as behavioral support, modified curriculums, visual schedules, and communication strategies (Terry, 2015, Richie, 2015). For education on sensory rooms, several studies explore the perceptions of healthcare providers using sensory modulation rooms (SMRs) after receiving some form of education and training. Healthcare providers believed proper education and training on SMRs would increase understanding and maximize use to promote improved experience amongst patients (Martin & Suane, 2012; Barbic et al., 2019, Proterra et al., 2021, Bjrkdahl et al., 2016). While research addresses the identified supports that can contribute to the presence and participation of children with disabilities in faith communities, there has been no recognized research to knowledge that addresses the application of these supports within faith-based communities. There is a multitude of congregational support faith-based communities can adopt to create an inclusive environment for children and youth with disabilities and their families. Research has highlighted larger churches are more likely to have support in place for youth and 6 children with disabilities compared to smaller churches (Ault et al., 2013a, Ault et al., 2013b, Carter et al., 2016,). Church of the Highlands is a multi-site church with thousands of members. Within their special needs ministry, Highlands Haven, they have various resources available to meet the needs of children with disabilities so they have a successful church experience. One of the resources they have is a sensory room. Approximately five of the twelve Haven ministries have a sensory room located on their campus. The sensory room is used to provide an environment that allows children to regulate their bodies when experiencing stressful or overstimulating stimuli. Items in the sensory room include a platform swing, weighted objects, tactile manipulatives, and items that produce sound or light. While they have this supportive environment to help children with disabilities in place, a gap identified within this ministry is the lack of knowledge volunteers have on how to use the sensory room to support participation in church-related activities. There is an identified need within Highlands Haven to develop and implement a sensory-friendly training program that educates Highlands Haven volunteers on how to properly use the sensory room and implement sensory strategies to best support the sensory needs of children in Haven. Although there is little research available on sensory-friendly program development in religious communities with faith community members, studies exist that examine the impact of various sensory integration strategies and programs utilized to increase participation in different environments. Information about how sensory integration programs are developed and perceived in other settings and by other personnel provided insight into this DCE project on how faithbased communities can adopt or create a training program and resources for a sensory room. Unlike most research that looks into sensory modulation rooms used in the clinical and school environment, this doctoral capstone project is different in how it explores the use and 7 effectiveness of a sensory modulation room in a faith-based community in order to increase participation in spiritual and religious-based activities. Theory and Frame of Reference The Person-Environment-Occupation (PEO) model was used to help guide this doctoral capstone project. This client-centered model helped guide the needs assessment to identify gaps and develop training materials to educate volunteers on sensory strategies to meet the sensory needs of children that attend Highlands Haven. PEO focuses on the person, environment, and occupation and how each construct works together to create a maximized fit for increased occupational performance (Cole & Tufano, 2008). According to the PEO model, dysfunction is when there is a poor fit between the person, environment, and occupation and therefore minimized occupational performance occurs for an individual (Cole & Tufano, 2008). Although the Highlands Haven ministry is equipped with the appropriate space, equipment, and resources to support children with special needs, a limitation of the ministry is the limited knowledge volunteers have on how to properly utilize the sensory room to meet the sensory needs of children in Haven. Volunteers' lack of knowledge and training impact their ability to perform their roles and responsibilities as volunteers, which then results in children who experience sensory dysregulation not successfully participating in their occupations related to spiritual and religious expression, successfully. In addition to the PEO model, the Sensory Integration (SI) frame of reference helped guide the project's program development. SI focuses on attention disorders, hypersensitivity to sensory stimuli, poor postural control and balance, apraxia, and inefficient cognitive processing (Cole & Tufano, 2008). Some items in the sensory rooms include a platform swing, a crash pad, fiber optic lights, and much more. When developing the training program, the SI frame of 8 reference helped guide the development of educational materials that were evidence-based and informed volunteers on strategies and items in the sensory room they can use to help children with sensory processing difficulties regulate. Information for the training included education on signs/symptoms of sensory integration and sensory processing disorders, education on how to increase self-awareness, and education on techniques to improve sensory regulation to increase children with special needs participation in congregational activities. Project Design The over-arching goal of this project was to develop a sensory-friendly training program and resources for Highlands Haven volunteers to help increase their understanding and maximize the use of the sensory room to meet the sensory needs of children with disabilities. It was determined best to deliver the training content to the Haven coordinators with functional sensory rooms versus directly to volunteers. This decision helped identify contact training personnel to deliver the material to volunteers after the initial program developer departed. Several discussions were held with the Central Haven director, Haven coordinators, and stakeholders consisting of occupational therapists and special educators across the Birmingham area to discuss the best method to design training. Feedback provided by these individuals led to the idea to create a curriculum and visual training materials that consisted of essential information about the sensory room and provided visual references of sensory strategies volunteers can use. While also creating and placing visual guides in the sensory room, this program design allowed information to be readily available when a volunteer is unsure how to help a child that is experiencing sensory modulation issues. This project utilized a quasi-experimental research design. This research design was deemed appropriate to test the effectiveness of the sensory-friendly training material. As an outcome 9 measure, a one-group pre-test post-test design looked at Haven coordinators and assessed the effectiveness of the sensory-friendly training material to see if there was an increase in Haven coordinators' understanding of the sensory room. Implementation initially started with creating content for the curriculum and visual guides. The information on the curriculum and visuals were based on common behaviors observed when a child is experiencing sensory processing difficulties and how specific items in the sensory room can be utilized to help a child regulate their sensory system. The educational materials were divided into three sections to address the following several sensory issues: sensory seeking, sensory sensitive or avoidant, and under responsiveness. The curriculum and visual guides used lay terms to describe behaviors and sensory strategies. The material were reviewed with the central Haven director several times until satisfactory. The content was delivered in-person and virtually. Due to time constraints of the site, the branding and transferring of educational materials to posters to display in the sensory rooms would occur postproject after the developers departure. Project Outcome To evaluate the effectiveness of the training material, a pre-test/post-test survey design was utilized. Utilization of the survey would demonstrate if there were any significant improvements in the Haven coordinators' knowledge of how to use the sensory room. Distribution of the survey occurred before and after the sensory room training. The electronic survey was sent to eight coordinators via email. Seven have a functional sensory room on their campus and one has a modified sensory room; a designated sensory room with a limited number of items. The survey consisted of 11-items that assessed their comfort and familiarity with using the sensory room in general and specific items in the sensory room. Coordinators assessed their 10 comfort and familiarity using the sensory room on a 5-point Likert scale ranging from 0-5, with zero being "not at all" and five being "extremely/extremely familiar." In the pretest survey, completed by seven coordinators, they briefly summarized what a sensory room is and its use. In the post-test survey, completed by six coordinators, they described what they learned from the training. Questions on the survey can be found in Table 1 and Table 2 in the Appendix. Prior to administering the training, coordinators and volunteers at several campuses with sensory rooms were observed. These observations helped gain a better picture in addition to the survey of the volunteers' comfort level of using the sensory room. Coordinators and volunteers' discomfort using the sensory room and frequent use of a standardized approach to help children overcome sensory processing difficulties were observed. Results of the pretest survey showed a range from slightly familiar to extremely familiar with how to use the sensory space. A significant finding was noted when measuring how familiar they are using the calm application with 57.1% of the coordinators responding not familiar pretraining, and 33.3% of participants reporting feeling somewhat familiar using the calming application, post-training. The coordinators were asked to describe the purpose of the sensory room prior to the training. Some responses stated, I feel comfortable for the most part in using the sensory room. I know it is not a playroom but a place for the kids to take a break, I know the sensory room is supposed to be used as a calming tool/place for children to calm down, and For the church, this is a space specifically designed to assist children with sensory needs to allow them to be successful in church. The coordinators were asked to recall one thing they learned from the sensory room training in the post-test survey. A few of the responses included "I learned explicit strategies for each item and how to train my team on each item" and "I appreciate having the difference between sensory seeking and sensory avoiding 11 behaviors." The responses demonstrate how the training improved their knowledge from general to more strategy-based to help promote successful church experiences. Based on the project outcomes there were several limitations to the project. The potential for benevolent biases was considered when interpreting the results. Due to the nature of the environment, the program developer anticipated the coordinators to rate their knowledge on a higher scale due to their appreciation of the program developers services. The coordinators were also made up of individuals who have some level of expertise or disability-related experience working with individuals with disabilities; therefore, their understanding of sensory processing and how to use the sensory room would be better compared to lay volunteers. Summary There is limited research that examines the presence and participation of children with disabilities and their families in faith-based communities. With the prevalence of children with developmental disabilities increasing and participation in spiritual and religious expression playing a prominent role in their life, there is a need to address this gap. Literature has suggested resolutions and future implications that highlight the need for education and training to address knowledge barriers. This doctoral capstone project aimed to bridge the gap by developing and implementing a sensory-friendly training program and resources for special needs ministry volunteers on how to properly use a sensory room. The project addresses one of the barriers that hinder children and youths successful participation in congregational life, knowledge barriers. Religious leaders and others are typically limited in the amount of knowledge they have about those with disabilities and how to meet their needs. Implementation of education and training amongst faith-based community members can help close this gap. The use of targeted knowledge and strategies that focus on 12 specific areas, such as sensory processing and integration, can be used to promote a successful church experience for children with disabilities. The results of this project demonstrate the benefits of efficient and proper education. Post-training Haven coordinators self-reported they felt extremely confident using equipment in the sensory room in a proper manner. Conclusion The goal of this project was to develop a sensory-friendly training program and resources for special needs ministry volunteers. Through the development of a sensory-friendly training program, the student was able to address the benefits of a training program that focused on sensory processing and integration and how it increased the understanding and use of sensory rooms in a successful manner to promote a positive church experience for children with disabilities. The site acknowledged the continued benefits that the program would have on current and future volunteers. This information can be valuable to occupational therapy practitioners and congregation leaders. Spirituality is within the realm of practice for OTs and is addressed in the Occupational Therapy Practice Framework (OTPF). This project explores how OT practitioners can address spirituality and how they can play a role in non-traditional settings such as a faith-based community. OTs can serve in roles that involve educating, consulting, and advocating. For faithbased communities, this can serve as a guide on how to implement training for volunteers on targeted knowledge and strategies that will encourage the congregational support of children and youth with disabilities. 13 References Ault, M. J., Collins, B. C., & Carter, E. W. (2013a). Congregational participation and supports for children and adults with disabilities: parent perceptions. Intellectual and Developmental Disabilities, 51(1), 4861. https://doi.org/10.1352/1934-9556-51.01.048 Ault, M., Collins, B., & Carter, E. (2013b). Factors Associated with Participation in Faith Communities for Individuals with Developmental Disabilities and Their Families. Journal of Religion, Disability & Health, 17(2), 184211. https://doi.org/10.1080/15228967.2013.781777 Barbic, S., Chan, N., Rangi, A., Bradley, J., Pattison, R., Brockmeyer, K., Leznoff, S., Smolski, Y., Toor, G., Bray, B., Leon, A., Jenkins, M., & Mathias, S. (2019). Health provider and service-user experiences of sensory modulation rooms in an acute inpatient psychiatry setting. PLoS ONE, 14(11), 115. https://doi.org/10.1371/journal.pone.0225238 Bjrkdahl A. Perseius, K., Samuelsson, M., Lindberg, M.(2016). Sensory rooms in psychiatric inpatient care: staff experiences: sensory rooms in psychiatric care. International Journal of Mental Health Nursing, 25(5), 472479. https://doi.org/10.1111/inm.12205 Carter, E. (2020). The Absence of Asterisks: The Inclusive Church and Children with Disabilities. Journal of Catholic Education, 23(2), 168188. https://doi.org/10.15365/joce.2302142020 Carter, E. (2016). A place of belonging: research at the intersection of faith and disability. Review & Expositor, 113(2), 167180. https://doi.org/10.1177/0034637316637861 Carter, E., & Boehm, T.(2019). Religious and spiritual expressions of young people with intellectual and developmental disabilities. Research and Practice for Persons with Severe Disabilities, 44(1), 3752. 14 Carter, E., Boehm, T., Annandale, N., & Taylor, C. (2016). Supporting congregational inclusion for children and youth with disabilities and their families. Exceptional Children, 82(3), 372389. https://doi.org/10.1177/0014402915598773 Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, N.J.: SLACK Inc. Lindsay, S., & Cancelliere, S. (2018). A model for developing disability confidence. Disability & Rehabilitation, 40(18), 21222130. https://doi.org/10.1080/09638288.2017.1326533 Liu, E. X., Carter, E. W., Boehm, T. L., Annandale, N. H., & Taylor, C. E. (2014). In their own words: the place of faith in the lives of young people with autism and intellectual disability. Intellectual and Developmental Disabilities, 52(5), 388404. https://doi.org/10.1352/1934-9556-52.5.388 Martin, B., Suane, S. (2012). Effect of training on sensory room and cart usage. Occupational Therapy in Mental Health, 28(2), 118128. https://doi.org/10.1080/0164212X.2012.679526 Proterra, K., Ehrlich, S., & Romani, P. W. (2021). Training direct-care staff to implement sensory integration strategies on a psychiatric inpatient unit. Journal of Child and Adolescent Psychiatric Nursing: Official Publication of the Association of Child and Adolescent Psychiatric Nurses, Inc, (20211024). https://doi.org/10.1111/jcap.12357 Richie, C. (2015). Do not hinder them: educating children with mental disabilities in the church. International Journal of Children's Spirituality, 20(2), 7285. https://doi.org/10.1080/1364436X.2015.1030593 Terry, K. (2015). A wrinkle in the fold: inclusion of people with autism spectrum disorders in faith communities. Social Work & Christianity, 42(4). 15 Whitehead, A. (2018). Religion and disability: Variation in religious service attendance rates for children with chronic health conditions. Journal for the Scientific Study of Religion, 57(2), 377395. https://doi.org/10.1111/jssr.12521 16 Appendix A Table 1. Highlands Haven Sensory Room Pre-Survey 1 2 3 4 5 6 7 8 9 10 11 How comfortable are you using the equipment in the sensory room in a successful manner? * 1 = Not at all, 2 = Slightly, 3 = Moderately, 4 = Very, 5 = Extremely How familiar are you with using the fiber optics in a successful manner? * 1 = Not at all familiar, 2 = Slightly familiar, 3 = Somewhat familiar, 4 = Moderately familiar, 5 = Extremely familiar How familiar are you with using the marble wall in a successful manner? * 1 = Not at all familiar, 2 = Slightly familiar, 3 = Somewhat familiar, 4 = Moderately familiar, 5 = Extremely familiar How familiar are you with using the platform swing in a successful manner? * 1 = Not at all familiar, 2 = Slightly familiar, 3 = Somewhat familiar, 4 = Moderately familiar, 5 = Extremely familiar How familiar are you with using the blue crash pad in a successful manner? * 1 = Not at all familiar, 2 = Slightly familiar, 3 = Somewhat familiar, 4 = Moderately familiar, 5 = Extremely familiar How familiar are you with using the peanut ball in a successful manner * 1 = Not at all familiar, 2 = Slightly familiar, 3 = Somewhat familiar, 4 = Moderately familiar, 5 = Extremely familiar How familiar are you with using the calm app in a successful manner? * 1 = Not at all familiar, 2 = Slightly familiar, 3 = Somewhat familiar, 4 = Moderately familiar, 5 = Extremely familiar How familiar are you with using the weighted blanket in a successful manner? * 1 = Not at all familiar, 2 = Slightly familiar, 3 = Somewhat familiar, 4 = Moderately familiar, 5 = Extremely familiar When a child appears to be experiencing sensory-seeking behavior, how comfortable are you with using at least 1 item in the sensory room in a proper manner? * 1 = Not at all, 2 = Slightly, 3 = Moderately, 4 = Very, 5 = Extremely When a child appears to be experiencing sensory sensitive behavior, how comfortable are you with using at least 1 item in the sensory room in a proper manner? * 1 = Not at all, 2 = Slightly, 3 = Moderately, 4 = Very, 5 = Extremely In a few words, what is your understanding of a sensory room? Table 2. Highlands Haven Sensory Room Post-Survey 1 2 3 How comfortable are you using the equipment in the sensory room in a successful manner? * 1 = Not at all, 2 = Slightly, 3 = Moderately, 4 = Very, 5 = Extremely How familiar are you with using the fiber optics in a successful manner? * 1 = Not at all familiar, 2 = Slightly familiar, 3 = Somewhat familiar, 4 = Moderately familiar, 5 = Extremely familiar How familiar are you with using the marble wall in a successful manner? * 17 4 5 6 7 8 9 10 11 1 = Not at all familiar, 2 = Slightly familiar, 3 = Somewhat familiar, 4 = Moderately familiar, 5 = Extremely familiar How familiar are you with using the platform swing in a successful manner? * 1 = Not at all familiar, 2 = Slightly familiar, 3 = Somewhat familiar, 4 = Moderately familiar, 5 = Extremely familiar How familiar are you with using the blue crash pad in a successful manner? * 1 = Not at all familiar, 2 = Slightly familiar, 3 = Somewhat familiar, 4 = Moderately familiar, 5 = Extremely familiar How familiar are you with using the peanut ball in a successful manner * 1 = Not at all familiar, 2 = Slightly familiar, 3 = Somewhat familiar, 4 = Moderately familiar, 5 = Extremely familiar How familiar are you with using the calm app in a successful manner? * 1 = Not at all familiar, 2 = Slightly familiar, 3 = Somewhat familiar, 4 = Moderately familiar, 5 = Extremely familiar How familiar are you with using the weighted blanket in a successful manner? * 1 = Not at all familiar, 2 = Slightly familiar, 3 = Somewhat familiar, 4 = Moderately familiar, 5 = Extremely familiar When a child appears to be experiencing sensory-seeking behavior, how comfortable are you with using at least 1 item in the sensory room in a proper manner? * 1 = Not at all, 2 = Slightly, 3 = Moderately, 4 = Very, 5 = Extremely When a child appears to be experiencing sensory sensitive behavior, how comfortable are you with using at least 1 item in the sensory room in a proper manner? * 1 = Not at all, 2 = Slightly, 3 = Moderately, 4 = Very, 5 = Extremely Briefly describe one thing you learned from the sensory room training. Table 3. Weekly Planning Guide Wee k 1 DCE Stage (orientation, screening/evaluation, implementation, discontinuation, dissemination) Orientation Weekly Goal Objectives Tasks 1) Complete orientation by end of the week Meet with site mentor, other site personnel to introduce myself and educate them on why I am here/what I will be doing the next 14-weeks Create a talking point document for when I meet with my site mentor about the project and plan for next 14weeks Ensure that all paperwork for Date complete 1/13/22 1/16/22 18 Understand site environment/dress code/expectations 2) Setup a weekly/monthly meeting with site mentor 3) Setup a weekly/monthly meeting with faculty mentor 3) Finalize MOU 2 Screening/Evaluation 1) Determine appropriate outcome measure assessment 3 Screening/Evaluation 1) Look at pretest/post-test survey designs Document supervision plan and update MOU with site mentor Document supervision plan and update MOU with faculty mentor orientation is completed. Set up a regular meeting with the site mentor (Wednesdays @ 1:30 PM CT) Set up a regular meeting with the faculty mentor (Fridays @ 8 AM CT) 1/12/22 1/17/22 1/17/22 Update MOU with ne1cessary information and update goals Research outcome measures and determine one that will be appropriate for program Research purpose, benefits, and limitations of outcome measure Meet with faculty and site mentor to address changes in MOU Confirm outcome 1/31/22 measure Create pre-test/ post-test survey 2) Observe Highlands Haven volunteers Familiarize self Journal with the routine of observations how Haven operates. 3) Review current Highlands Haven sensory room training Look at sensory training programs in other settings (schools, clinics, etc.) 1/31/22 Every Sunday Read two to four Weekly articles about training programs in other settings and 19 faith-based settings 4 5 6 Screening/Evaluation 1) Observe Highlands Haven volunteers Implementation Implementation Observe how volunteers work with children and utilize sensory room Create an inventory list of items in sensory rooms 2) Continue reviewing current Highlands Haven sensory room training Look at sensory training programs in other settings (schools, clinics, etc.) Read four to five articles about sensory processing and sensory room training programs 3) Brainstorm training material design Get insight from site mentor, faculty mentor, and stakeholders on program design 1) Develop sensory room training curriculum + visuals Research EBP articles that support sensory interventions for items in sensory room Come up with several material design formats electronic, paper, and graphic visuals - and run them by site mentor Create an outline for training and review with site mentor 2) Create graphic visuals for sensory room Create graphics and review with site mentor to receive feedback 1) Develop sensory room training material Create graphics and review with 2/12/22 2/10/22 Organize training material by 2/15/22 sensory issues: sensory seeking, sensory avoidant + sensitive, and under-responsive Email sensory 2/16/22 room training 20 7 Implementation 1) Develop sensory room training site mentor to receive feedback drafts to pediatric OT stakeholders Create graphics and review with site mentor to receive feedback Send email to 2/22/22 Haven coordinators with a functional sensory room. 8 Implementation 1) Develop sensory room training 9 Implementation 1) Implement sensory room training 10 Implementation 1) Interpret results Gather data from pre-test/post-test 11 Implementation 12 Discontinuation 1) Potentially meet with the creative team to brand content for Highlands and transfer content to poster format 1) Create a presentation for dissemination plan Discuss formatting training material into a poster so can deliver to creative for branding and development Sensory training will be presented to either Central HK Team or to a group of Highlands college students Brainstorm with site mentor on how to present information and receive feedback before first training session Educate Highlands Haven Coordinators on the sensory room training material. Send pre-test survey prior to training Finish creating sensory room training material 2/22/22 Send post-test survey after training 3/6/22 3/1/22 Create Excel 3/17/22 sheet with survey data Send training 4/7/22 material to site mentor for her to send it to creative team Select date to present Gather needed materials for presentation 3/30/22 21 13 Discontinuation 1) Present training information to Central Highlands Kids team 14 Dissemination 1) Complete final evaluation of the project with site mentor Training material is a part of Highlands Kids Highlands Haven curriculum. Present new sensory training to team Meet with site mentor to review progress over the past 13-weeks Meet with site mentor to review progress over the past 14-weeks Finish presentation and present to Central Highlands Kids team 4/5/22 Complete site evaluation 4/15/22  ...

... 1 Social Participation Resources for Children in Special Needs Sunday School Classrooms Rachel Jones May 22, 2022 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Kristina Watkins, OTD, MOT, OTR 2 Abstract Background: Northview Church Carmel serves a diverse population within their Special Needs Ministry. Those served would benefit from a system to enhance community engagement and increase social participation with their typically developing peers. Introduction: The author developed resources including social scripts and social stories to increase social participation. Project Design: A pre-test/post-test was utilized to examine knowledge of social participation resources before and after intervention. Six Special Needs Ministry volunteers participated in testing. Outcomes: Participants demonstrated an increase in knowledge and understanding of social participation resources following intervention. Participants scored a 35% increase in mean, a 30% increase in median, and a 30% increase in mode scores from pre-test to post-test. Participants scored a mean of 92%, with median and mode scores of 90%. Conclusions: Future research should examine the impact of OT within church programs and worship settings. Results of this project support integration of OT in the church. 3 Introduction Northview Church Carmel is the Carmel, IN campus of the multi-site nondenominational Christian church Northview Church, (Northview Church, 2021). The mission of Northview is to connect people with God and connect people with people (Northview Church, 2021). Northview Church Carmel serves a wide population of diagnoses within their Special Needs Ministry. They serve children and youth with diagnoses that include ASD, SPD, learning disabilities, hearing impaired, visually impaired, immunocompromised, and food allergies. They also serve children, youth, and young adults who utilize ventilators, g-tubes, and cochlear implants (Northview Church, 2021). This population would benefit from a system to enhance community engagement and increase social participation with their typically developing peers. This Doctoral Capstone Experience (DCE) project aimed to create social participation resources for children and youth in Northview Carmels Special Needs ministry. By developing these resources tailored to the populations needs, this DCE project enabled children and youth within the Special Needs Ministry to increase their social participation with peers and support spiritual growth at each participants individual level. Program volunteers and the Special Needs Ministry coordinator would also utilize these resources to support the children and youth during Northview youth events and Sunday worship services. As current research shows, developing individualized social participation resources for Northview Carmels Special Needs Ministry Youth would increase the target populations interaction with their peers across the development spectrum while supporting their personal faith (Carter et al, 2017; Leal 2018). This DCE project design supported the 4 current practices at Northview Carmel while seeking to address some of the stakeholder goals to increase accessibility and diversity in program and campus resources. This report expands on Northviews rich background and additional needs relevant to the target population. Current literature supporting this DCE project is summarized below, with critique included. The author details the theory and frame of reference this project is grounded in, highlighting the connection between the project design and these theoretical concepts. Finally, the author maps the DCE project outcome, including outcome measures, statistics, and relevant observations collected during the course of this experience. Background Northview Church Carmel serves a wide population of diagnoses within their Special Needs Ministry. They serve children and young adults who require a vent, have a tracheostomy, require a gastrostomy tube, have autism spectrum disorder, have a sensory processing disorder, are extremely immunocompromised, have cochlear implants, are legally blind, have learning disabilities, and have a variety of dietary allergies. These allergies include dairy, gluten, nut, and various other allergy triggers (Northview Church, 2021). Based on the information gained during the needs assessment, the children and youth served by Northview Church Carmels Special Needs Ministry would benefit from a system to enhance community engagement and increase social participation with their typically developing peers. The focus of this project was on developing resources including social scripts and social stories for children and youth with various diagnoses to increase social participation with their peers, the general church congregation, and the surrounding community. 5 Leal (2018) highlighted both the history of Sunday school programs in America and the importance of these programs in establishing faith and service for children and youth in the Christian church. Whitehead (2018) found that children with autism spectrum disorder, ADHD, conduct disorders, bone or joint or muscle conditions, learning disabilities, and developmental delays are among populations more likely to never attend services. Conditions impacting social interaction and communication may also decrease church attendance or engagement with others at a church event (Whitehead, 2018). Carter et al. (2017) examined the relationship of faith, disability, and increasing inclusion of persons with disabilities and their families in the church. Carter et al. (2017) provided great support for including persons with disabilities within the church service and activities, which aligns with the goals of the staff at Northview Church Carmel. Carter et al. (2017) cited multiple ideas for increasing this inclusion in different aspects of church worship. Richie (2015) focused on educating children with intellectual and mental disabilities in the Christian church setting. Richie (2015) stressed that teachers within the church have a duty to educate children at all cognitive levels and abilities, and resource design must reflect this These concepts were integral to this project, as Richies research definitively supported developing specific resources tailored to the needs and cognitive levels of young adults and children with disabilities. Creating resources to present Christian teachings at the intellectual level of each student not only fulfills the goals of the inclusive Sunday school classroom but falls in line with Biblical teaching promoting children in the church through the belief that Heaven belongs to them also (Richie, 2015). Laszlo and Buren (2014) developed an informational booklet designed for Jewish communities to assess and adapt their current services and resources to support and include 6 Jewish children with disabilities and their families within the synagogue congregation. Laszlo and Burens (2014) work included an initial self-assessment for communal service leaders to examine their current service practices and assess the inclusion of children and families with disabilities within the congregation. Based on the results of this assessment, leaders and staff could complete a fifteen-step guide to promoting this inclusion in their services and programs (Laszlo & Buren, 2014). Laszlo & Burens (2014) study is similar in design to this project as volunteers completed a pre/post knowledge test then received educational packets to increase volunteer understanding and use of social participation resources. While Laszlo & Burens (2014) guide resource was designed for persons of the Jewish faith, a Christian church congregation can adapt many of its concepts. In contrast to Laszlo & Buren, the current project focuses on providing resources for volunteers within an existing Special Needs Ministry as opposed to the congregation as a whole. Sango and Forrester-Jones (2018) examined the impact of spirituality and religious community on social interaction for persons with intellectual and developmental disabilities (IDD). Researchers found that such services and communities have an integral role in expanding social circles for persons with IDD (Sango & Forrester-Jones, 2018). Sango and Forrester-Jones (2019) examined spiritual care for individuals with disabilities in faith-based and non-faith-based care facilities. Researchers found that caring and providing support for this population, when desired, could support spirituality and patient needs by addressing the significance and importance spirituality has to individuals in these facilities (Sango & Forrester-Jones, 2019). Sango & Forrester-Joness (2018) results were similar to this project as they stressed the importance of providing spiritual care, education, and support to individuals with disabilities when they desire it. Sango and Forrester-Joness (2019) results 7 can apply to the church setting by designing resources for young adults with disabilities addressing their individual spiritual, physical, and cognitive needs. While the populations in Sango & Forrester-Joness studies do not match the age range of students at Northview Church Carmel, the importance of providing spiritual support to persons with disabilities rings true for both populations (Sango & Forrester-Jones, 2018; Sango & Forrester-Jones, 2019). Developing individualized social participation resources for the Northview Carmel Special Needs Ministry children and youth will increase the target populations interaction with their peers across the development spectrum while supporting their personal faith. This project design supported the current practices at Northview Carmel while seeking to address some of the stakeholder goals to increase accessibility and diversity in program and campus resources. Theory and Frame of Reference The Kawa Model and Sensory Integration frame of reference were key resources for this DCE project. The Kawa provided a clear visual picture of the existing barriers and supports to success and function at this site (Iwama et al., 2009). Supports and barriers included site staff or volunteers, the expansive physical church campus, accessibility features in and around classrooms, and staff training. These aspects provided support for project and program development in the Special Needs Ministry, highlighting a clear picture of the existing barriers and supports onsite, clarifying the need for a modification in program development which this DCE capstone address. Utilizing the Kawa Model as a guiding mindset during project development examined every aspect of the population, available resources, routine modification, etc., through long and short-term application (Iwama et al., 2009). This supported program 8 sustainability, a concern for stakeholders at Northview Carmel. The longitudinal component of the Kawa Model depicted the overarching timeline for this project and kept development, implementation, and assessment on schedule (Iwama et al., 2009). Like the Kawa Model, Ingersoll (2014) examined barriers to children expressing their faith and spirituality within the church. Research supported the importance of providing spiritual opportunities for growth to children and youth in the church (Ingersoll, 2014). The church is a source of faith and support for many persons of all ages, and as such, the church programming should enable spiritual growth and increase faith for each of the members they serve, particularly those with disabilities. By highlighting the barriers to spirituality for children within the church, Ingersoll (2014) shed light on the role of the church to support its members in increasing knowledge and faith through a Sunday school curriculum focused on the worship experience for young adults with disabilities. This allowed the target population for this DCE project to take an active role in their faith experience and strengthen their spirituality to support their confidence and success in other occupations in their lives. A Sensory Integration frame of reference was invaluable during project implementation (Cole & Tufano, 2008). Cultivating resources to increase social participation for children and youth in the Special Needs Ministry at Northview Carmel aligned completely with Hamiltons (2019) study on including persons with learning disabilities within church services. Hamilton (2019) suggested that Biblical teaching mandates that all human beings are Gods creation, called to Heaven through the Holy Ghost, making all person equal in Gods view. These findings greatly supported addressing inclusion for individuals at all levels and from all backgrounds in the church, including those with disabilities. Utilizing a Sensory Integration frame of reference ensured that group size, duration of events, and possible reactions to various stimuli are 9 addressed when implementing and assessing the developed resources (Cole & Tufano, 2008). Project Project Design The Special Needs Coordinator at Northview Church Carmel expressed concerns with the inclusivity of current resources and events at Northview Carmel. She noted a desire for resources that staff and volunteers could utilize to ensure that activities were at a clear understanding level for all children served. The primary goal for this project included ensuring that any program expansions were sustainable so more needs were met. Based on the information gained from the needs assessment, the author determined that this population would benefit from a system to enhance community engagement and increase social participation with their typically developing peers. To meet this populations need, the current project focused on developing social scripts and social stories for children and youth with a variety of diagnoses to increase social participation with their peers, the general church congregation, and the surrounding community. The Institutional Review Board from a midwestern university determined that this project did not meet the definition of human subject research and as such the author was not required to submit a research proposal for full review. Project development included assessing current community participation for this population and completing program and resource development. A weekly description of project tasks is listed in the Appendix. Resources included compiling volunteer education packets, binders, and portable flip books about social stories and social scripts to provide a more diverse engagement in current lessons and ministries. 10 A pre-test/post-test was utilized to examine volunteers knowledge of social participation resources prior to and following intervention. Kelley et al. (2012) utilized a preand post-test to examine improving the health and wellness of African American grandmothers raising grandchildren. Kelley et al. (2012) completed data collection at baseline and after the conclusion of intervention to examine the change in health and wellness in their study participants. Ison et al. (2010) used a pre- and post-test to assess the intervention effect and explore participant evaluations of the [implemented] disability awareness programme (p. 362). Researchers in Isons (2010) study administered baseline pre-tests prior to intervention and administered the same test as a post-test up to two weeks following intervention completion. Nam (2013) utilized a pre- and post-test to examine the impact of a spirituality-based intervention on weight loss in African American women living in a rural area. Baseline data was collected via the pre-test prior to intervention and data was collected via the post-test following a 10-week intervention (Nam, 2013). Implementation Pre-tests were distributed prior to intervention. Six Special Needs Ministry volunteers at Northview Carmel were included in this project. Post-tests were distributed following the end of intervention period. Intervention included distributing educational packets to all Special Needs Ministry volunteers. Packets included education on social participation resources including social scripts and social stories, collected and developed by the author. Volunteers expressed great enthusiasm throughout this project and were eager to participate in all aspects of the project. Volunteers demonstrated an increase in knowledge of social participation resources, as indicated by post-test scores in Table 2. Staff, volunteers, and 11 children were impacted by COVID-19 throughout the course of this project. Some volunteers and children have yet to return due to increased risk of contracting COVID-19, as many of the children in the Special Needs Ministry have compromised immune systems at baseline. Project Outcomes Number of Participants Pre-test Scores Mean Pre-test Score Median Pretest Score Mode Pre-test Score n= 6 60% 57% 60% 60% 60% 70% 30% 40% 80% Table 1. Pre-test data including number of participants (n=8), scores, mean, median, and mode scores. The author assessed volunteers knowledge and understanding of social scripts and social stories using a pre/post-test format. The author developed this pre-test consisting of multiplechoice questions about the definition, components, and use of social scripts and social stories. Participants completed the pre-test prior to intervention and scores were recorded by the author. Following the intervention period including distribution of education packets participants completed the post-test and scores were recorded. As noted in Table 1, the mean score for pre-test was 57%. The author noted a median score of 60%, with 60% also the score recorded most frequently. Participants scores ranged from 30% - 80%, with no participants scoring 90% or above on the pre-test. See Figure 1 for a distribution of participant scores. Participants were not informed of scores and the author removed all identifying components from data to ensure anonymity. 12 Number of Participants Post-test Scores Mean Post-test Score Median Posttest Score Mode Post-test Score n=6 90% 92% 90% 90% 80% 90% 90% 100% 100% Table 2. Post-test data including number of participants (n=8), scores, mean, median, and mode scores. Similar to Ison et al.s (2010) study, the author administered the same test as a post-test up to a week following intervention completion. Participants completed the test and scores were recorded by the author. Participants were not informed of scores and the author removed all identifying components from data to ensure anonymity. As noted in Table 2, the mean score for post-test was 92%. The author noted a median score 90% with 90% also the post-test score recorded most frequently. Participants scores on the post-test indicate an increase in knowledge and understanding of social scripts and social stories, as demonstrated by a 35% increase in mean, a 30% increase in median, and a 30% increase in mode scores. See Figure 2 for a distribution of participant scores. 13 Pre-Test Scores 100% 90% Score Percentage 80% 70% 60% 50% 40% 30% 20% 10% 0% 1 2 3 4 5 6 5 6 Participant Figure 1. Bar chart comparing pre-test scores for participants. Post-Test Scores 100% 90% Score Percentage 80% 70% 60% 50% 40% 30% 20% 10% 0% 1 2 3 4 Participants Figure 2. Bar chart comparing post-test scores for participants. 14 Summary Northview Church Carmel serves a diverse population within their Special Needs Ministry. As noted following a needs assessment, the children and youth served by Northview Church Carmels Special Needs Ministry would benefit from a system to enhance community engagement and increase social participation with their typically developing peers. The focus of this project was on developing resources including social scripts and social stories for children and youth with various diagnoses to increase social participation with their peers, the general church congregation, and the surrounding community. A pre-test/post-test was utilized to examine volunteers knowledge of social participation resources prior to and following intervention. Six Special Needs Ministry volunteers at Northview Carmel were included in this project. Intervention included distributing educational packets to all participating Special Needs Ministry volunteers. Packets included education on social scripts and social stories collected and developed by the author. Participants demonstrated an increase in knowledge and understanding of social participation resources following education intervention. The authors analysis of objective data indicated a 35% increase in mean score on the post-test, a 30% increase in median score, and a 30% increase in mode score when comparing pre-tests to post-tests. Participants scored a mean of 92%, with median and mode scores of 90% and 90%, respectively. Conclusions 15 The author developed social scripts and social stories for children and youth with a variety of diagnoses to increase social participation with their peers, the general church congregation, and the surrounding community. Project development included assessing current community participation for this population and completing program and resource development. Resources include compiling volunteer education packets, binders, and portable flip books about social stories and social scripts to provide a more diverse engagement in current lessons and ministries. A pre-test/post-test was utilized to examine volunteers knowledge of social participation resources prior to and following intervention. The Northview Carmel Special Needs Ministry volunteers demonstrated an increase in knowledge and understanding of social participation resources and the benefit of these resources in the Sunday school classroom. Staff and volunteers expressed their gratitude following education and demonstrated excitement and interest throughout the course of this project. All educational materials, examples, and social participation resources were presented to Special Needs Ministry staff for continued use in the Special Needs Ministry. The outcomes of this project support the role of OT within the church setting. Future research should examine the impact of OT within additional church programs including adult classes, congregational events, and general mixed worship settings. The success of this project supports continued integration of OT into the church setting. 16 References Carter, E. W., Bumble, J. L., Griffin, B., & Curcio, M. P. (2017). Community conversations on faith and disability: Identifying new practices, postures, and partners for congregations. Pastoral Psychology, 66(5), 575594. https://doi.org/10.1007/s11089017-0770-4 Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK Incorporated. Hamilton, R. (2019). The inclusion of people with a learning disability in the church: A case study. Journal of European Baptist Studies, 19(2), 117130. Ingersoll, H. N. (2014). Making room: a place for childrens spirituality in the Christian church. International Journal of Childrens Spirituality, 19(3/4), 164178. https://doi.org/10.1080/1364436X.2014.979774 Ison, N., McIntyer, S., Rothery, S., Smithers-Sheedy, H., Goldsmith, S., Parsonage, S., & Foy, L. (2010). Just like you: A disability awareness programme for children that enhanced knowledge, attitudes, and acceptance: Pilot study findings. Developmental Neurorehabilitation, 13(5), 360-368. https://doi.org/10.3109/17518423.2010.496764 Iwama, M.K., Thomson, N.A., & Macdonald, R.M. (2009). The Kawa model: The power of culturally responsive occupational therapy. Disability and Rehabilitation, 31(14), 1125 17 1135. https:/doi.org/10.1080/09638280902773711 Kelley et al. (2012). African American caregiving grandmothers: Results of an intervention to improve health indicators and health promotion behaviors. Journal of Family Nursing, 19(1), 53-73. https://www.doi.org/10.1177/1074840712462135 Laszlo Mizrahi, J., & Buren, M. (2014). Serving Jewish children with disabilities and their families. Journal of Jewish Communal Service, 89(1), 8392. Leal, K. E. (2018). All our children may be taught of God: Sunday schools and the roles of childhood and youth in creating evangelical benevolence. Church History, 87(4), 10561090. https://doi.org/10.1017/S0009640718002378 Nam. (2013). Effects of social support and spirituality on weight loss for rural African-American women. The Association of Black Nursing Faculty Journal, 24(3), 7176. Northview Church. (2021). Welcome to Northview. Northview Church. https://northviewchurch.us/ Richie, C. (2015). Do not hinder them: educating children with mental disabilities in the church. International Journal of Childrens Spirituality, 20(2). p. 7285, http://dx.doi.org/10.1080/1364436X.2015.1030593 Sango, P. N., & Forrester-Jones, R. (2019). Spiritual care for people with intellectual and developmental disability: An exploratory study. Journal of Intellectual & Developmental Disability, 44(2), 150160. https://doi.org/10.3109/13668250.2017.1350834 18 Sango, P. N., & Forrester-Jones, R. (2018). Spirituality and social networks of people with intellectual and developmental disability. Journal of Intellectual & Developmental Disability, 43(3), 274284. https://doi.org/10.3109/13668250.2017.1310820 Sargeant, M. A. A., & Berkner, D. (2015). Seventh-Day Adventist teachers perceptions of inclusion classrooms and identification of challenges to their implementation. Journal of Research on Christian Education, 24(3), 224251. https://doi.org/10.1080/10656219.2015.1104269 Whitehead, A.L. (2018). Religion and disability: Variation in religious service attendance for children with chronic health conditions. Journal for the Scientific Study of Religion 57(2) p. 377395. 19 Appendix Doctoral Capstone Experience and Project Weekly Planning Guide Week 1 DCE Stage Weekly Goal (orientation, screening/eva luation, implementati on, discontinuati on, dissemination ) Orientation Complete orientation by end of the week Objectives Tasks Meet with site mentor, campus staff, and central staff to introduce myself and foster conversation on the aim of my DCE project and my role onsite for these next 14 weeks. Begin additional research for updating Lit Review Familiarize myself with the site layout, dress code, workstation, schedule, etc. 2 Screening/E valuation Complete final draft Finalize orientation questions/co ncerns Finalize Outcome Date complete 1/14/22 Make sure all orientation paperwork and signatures for site are complete Begin rough draft of pre/posttest for volunteer evaluation. Continue research for 1/23/22 20 and key for assessment pre/posttest (pre/posttest for volunteer ) evaluation. Distribute pretest to site volunteers at weekend services 3 4 5 6 updating Lit Review Meet with site mentor to discuss outcome measure for clarity Distribute pretest to volunteers Screening/E Distribute Wrap-up Distribute 1/30/22 valuation pretest to screening/ev remaining remaining aluation and pretests and site score for collect volunteers at baseline completed. weekend scores Score tests services for baseline knowledge scores. Implementat Begin Start Start 2/6/2022 ion developing developing gathering resources for social and volunteer participation organizing education resources for resources for volunteers volunteers Implementat Organize Finalize Finalize 2/13/2022 ion instructions instructional instructional to create resources for packets for social volunteers volunteers scripts/storie s Review packet with site mentor for clarity and feasibility Implementat Distribute Provide Pass out 2/20/2022 ion packets to instructional packets to volunteers packets to volunteers during volunteers during weekend and check weekend services for feedback services 21 and clarification 7 8 9 10 11 Implementat Discuss ion resources with volunteers and team members Facilitate additional resource instruction Be available for clarification and feedback Attend weekend service to discuss packets with volunteers Provide clarification and instruction when necessary Implementat Organize Observe Update final ion feedback social resource from last participation materials as weeks resources in needed service and practice update final Continually resources as discuss necessary resources with site mentor Implementat Supervise/in Observe Supervise/w ion teract with social ork with volunteers to participation volunteers gain resources in during leadership practice weeknight experience childcare event Implementat Collect Administer Distribute ion outcome posttest posttest measures during during during weekend weekend weekend services services services Implementat Continue to Administer Distribute ion collect posttest posttest outcome during during measures weekend weekend during services services 2/27/2022 3/6/2022 3/11/22 3/18/22 3/25/22 22 12 13 14 weekend services Implementat Continue to ion collect outcome measures during weekend services Discontinuat Wrap up ion project observation/i mplementati on. Disseminatio Present final n project and outcomes to site stakeholders /site mentors Administer posttest during weekend services Distribute remaining posttest during weekend services 4/3/22 Gather volunteer feedback and outcome measures from past weeks of program implementat ion. Collect completed posttests from volunteers and grade 4/8/22 Finalize outcome measures, academic paper, and presentation for site Document outcome measures (change in score on pre/posttest) Finalize disseminatio n presentation Organize final resources for facility staff 4/15/22  ...

... Sensory Assessments at the Museum: Evaluating Sensory Features in Exhibits for Community Accessibility Patia Hunt May 2022 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Dr. Taylor Gurley, Assistant Professor Abstract Experts and current literature suggest that sensory stimuli affect accessibility and participation in varying environments; however, studies presented limited understanding of what and how sensory stimuli within an environment might pose as barriers compared to educational and immersive experiences. I partnered with The Childrens Museum of Indianapolis to produce quantitative and qualitative assessment tools specific to the museum-setting to identify sensory features within exhibits. We collaborated to develop a quantitative tool (M-SEAT) and qualitative tools (exhibit and interactive ASI appraisals) based on literature, expert opinions, education, and clinical experiences to identify characteristics of sensory stimuli in environments that may present differences in accessibility for those with sensory-related difficulties, as well as provide more awareness for museum evaluators regarding the designs of the exhibits. Each tool is anticipated to provide different interpretive information to support knowledgeable exhibit design, preparation, and community accessibility and promote The Childrens Museum of Indianapolis as a role model for accessibility and inclusion. Keywords: sensory, accessibility, museum, occupational therapy, assessment tool, children, pediatrics, community, sensory processing, sensory integration, emerging practice, The Childrens Museum of Indianapolis, immersive experience, exhibit, environmental design Introduction The Childrens Museum of Indianapolis (TCM) provides unique opportunities for families to learn, play, and interact via exhibits and events within the community setting. TCM partners with many community initiatives and organizations to serve as a role model and support their visitors and neighboring communities. Interested parties may visit the museum in many ways, but TCM strives to ensure the best experience for all its visitors, such as families, children or adults with disabilities (mobility, vision, hearing, developmental, etc.), foster families, or school groups. Although TCM is a non-profit organization and utilizes grant funds for initiatives pursuing inclusive and accessible environments, universal design and maintaining the integrity of artifacts may not allow for true accessible features (Carron, 2015). Teams of staff members work to make the best environment and experience while maintaining their goals of safety, family learning, inclusion, and valuable visitor experience. These teams often include representatives from several departments: exhibit development and design, marketing, operations, research and evaluation, interactive programming, collections, production, visitor and public relations, security, graphics and technology, finance, specialists, and others, as indicated. Each member in the development and maintenance phases of an exhibits lifetime at TCM is responsible for considering how exhibit elements may affect visitor experience, which reflects onto the museum as a whole. Within recent years, TCM received a grant from the Institute of Museum and Library Services (IMLS) to support budgeting renovations of the Dinosphere exhibit, the largest and longest lasting exhibit at TCM (The Childrens Museum of Indianapolis, n.d.). Portions of the IMLS grant heavily focus on goals related to accessibility and inclusion to elicit innovation to museum exhibit design and visitor experience, and TCM fully supports this reimagined perspective. In the past, TCM developed a few resources, collaborated with advisors and families, and held specialized events for those with differing accessibility needs in order to access the museum. With the Dinosphere renovation and support from this grant, TCM is pushing accessibility and inclusion boundaries to surpass universal design and ADA standards when able, while also maintaining collections concerns and building restrictions. As indicated, not all pieces of immersive experiences or collections items may be accessible, and we still weigh the options for what the general population might benefit from and how we might accommodate experiences that do not feature universal design recommendations. As my doctoral capstone project for occupational therapy, I worked at TCM under the Operations Project Manager and Accessibility Coordinator and alongside the Director of Research and Evaluation to develop methods that evaluate an environment (in this case an exhibit) for sensory stimuli characteristics to promote awareness for how sensory elements may affect accessibility and the learning environment. In doing so, TCM staff could assess their exhibits on which sensory stimuli are present, to what degree they are present, if the stimuli are varied or concentrated, or any other features that might interconnect with access. Background Sensory processing and self-regulation are key elements of how individuals experience life and form a foundation for other developmental milestones (Cho, n.d.-a; Cho, n.d.-b; Kranowitz, 2005; & STAR Institute, n.d.). Each individual utilizes eight senses to coordinate their body, surroundings, and decisions: five external senses auditory or sound, gustatory or taste, olfactory or smell, tactile or touch, and visual or sight; and three internal senses interoception or internal body awareness like hunger or heart rate, proprioception or muscle sense like movement, and vestibular or head position in space and balance (Kranowitz, 2005; Parham & Mailloux, 2020). Using these, a person collects information through different sensors or structures, transports the information across neural pathways to the brain and spinal cord, processes it for understanding, and makes a decision regarding the sensory input, determining if it signifies a threat and if, or perhaps how, to acknowledge the information (Kranowitz, 2005; Parham & Mailloux, 2020) Through exposure, practice, and social interactions, an individual may develop and refine their sensory processing and regulation skills throughout life; children often have more difficulty honing these skills due to naivety and dependency for exposures (Kranowitz, 2005). Frequently, people experience occasional, minor difficulties processing and regulating sensory stimuli while developing and mastering skills; this is anticipated and not indicative of a sensory-related issue. On the contrary, some individuals may demonstrate more prominent signs and symptoms of sensory-related problems, such as tantrums, significantly reduced focus, unnoticed or excessively noticed features within the environment, and other behaviors; parents or educators may consult with therapists to address notable issues when they impact daily functioning: retaining an inappropriate behavior pattern for an extended period of development; severe, disrupting, potentially harmful, or destructive behaviors; behavior bouts last a long time before recovering, or behaviors that occur frequently (Cho, n.d.-a; Dunn, 2007; Kranowitz, 2005; & Parham & Mailloux, 2010). Jane Ayres, an occupational therapist highly prominent around the 1970s, studied this phenomenon to create the foundation for sensory integration research and therapy interventions to mediate these behaviors (Cho, n.d.-b; Parham & Mailloux, 2010; & Parham & Mailloux, 2020); since then, others like Winnie Dunn have evolved upon these concepts to appreciate how sensory processing and regulation affected children, how environments posed sensory stimulation that might promote or limit occupations based on a childs skills, developed assessment tools to quantify and recognize sensory-related needs, and suggested varying methods and specialties for therapeutic considerations (Cho, n.d.-a; Dunn, 2007; Kranowitz, 2005; Parham & Mailloux, 2010; & Parham & Mailloux, 2020). Researchers hypothesized these concerns may stem from a neurological reason, such as underexposure or misalignment with what is considered socially appropriate behaviors, may be associated as symptoms from other diagnoses, or may be both and considered as comorbidities (Kranowitz, 2005: Parham & Mailloux, 2020). Foundational leaders categorized observable sensory processing symptoms based on these areas of difficulties: modulation (sensory seeking, avoidance or defensiveness, and low registration), sensorimotor (motor control, balance, coordination, body awareness), and discrimination or the ability to differentiate between types of sensory input and processing (Kranowitz, 2005). Sensory processing disorder (SPD) is not a recognized medical diagnosis because of its complexity and lack of formal research; however, SPD is commonly acknowledged in pediatrics and OT as an association of sensory-related problems, as described in the above categories, interfering with daily occupations (Kranowitz, 2005). Literature supported the notion that sensory-related issues might precede and exacerbate other diagnoses and symptoms, including but not limited to autism spectrum disorder, attentiondeficit/hyper-activity disorder, behavioral challenges, anxiety, sleep complications, learning deficits, family dynamics and social interruptions, and digestion and mealtime complications (Blanche et al., 2016; Bodison & Parham, 2018; Cahill & Beisbier, 2020; Carpenter et al., 2019; Kirby et al., 2015; Kirby et al., 2019; Vasak et al., 2015; Woo & Leon, 2013; & Zobel-Lachiusa, et al., 2015). Additionally, Bodison and Parham (2018) stated that sensory-related challenges in children increased over the last 20 years; unfortunately, the COVID-19 pandemic with isolation and mask mandates presents an increased risk for sensory deprivation to this generation of children. Therefore, integrating sensory-related design features into a positive community-based, interactive environment promotes the exposure and practice with sensory integration and processing required for skill development. Sensory integration intervention researchers recommended increased exposure in occupation-based, multi-faceted, and engaging methods as best practice for this area of skill development (Cho, n.d.-a; Kranowitz, 2005; Parham & Mailloux, 2020; Reynolds, et al., 2017; & STAR Institute, n.d.). As play and education are childrens main occupations, the museum provides an intentional atmosphere to incorporate skill development through occupations appropriate for this age (American Occupational Therapy Association, 2020; & Carron, 2015). Researchers also suggested that sensory exposure to all individuals, regardless of client factors, demonstrated benefits to skill development, and this skill refinement might transfer into other areas of performance, promoting the versatile use of sensory-informed decision making (Blanche et al., 2016; Cahill & Beisbier, 2020; Smart et al., 2018; & Woo & Leon, 2013). My intention for this project is to enhance TCM staff members knowledge regarding sensory stimulation and accessibility, so that they may be more intentional and aware about the sensory features their exhibits possess. The partners and author required methods to quantify and acknowledge the sensory features present within the exhibit experience to provide accessible exhibits and promote sensory-related skills, as the museum strives for unique experiences and learning. Individuals must learn through sensory information, being told, shown, or engaged in learning materials; therefore, literature recognized that sensory-skill advancement corresponds with improved educational skills (Dunn, 2007; Kranowitz, 2005). As an extension to this, researchers hypothesized that sensory-skill refinements may also lead to diminished risks for maladaptive behaviors, symptom severity, and development of other disorders in the future, as well as improve sensory skills that form the foundation for other development skills such as social skills, coping efficiency, memory and cognition, occupational performance, physical functioning and efficiency, and mood (Baroncelli, et al., 2010; Blanche, et al., 2016; Carpenter, et al., 2019; Cho, n.d.-b; Clark & Hasse, n.d.; Kirby, et al., 2019; Mandolesi, et al., 2017; Scholz, et al., 2015; & Vasak, et al., 2015). In turn, these children may be better prepared for success and full engagement. Foundational Basis Based on the Person-Environment-Occupation-Performance (PEOP) model, Dunns Model of Sensory Processing, and the Sensory Integration (SI) frame of reference, I will negotiate how to develop tools to acknowledge the dynamic relationship between a person, an environment and its sensory features, the occupation or activities, and their performance. The PEOP model endorses the creation of an enabling environment in which an occupation occurs, such as play and informal education, to promote skill development (Bass, Baum, & Christiansen, 2017; Baum & Christiansen, 2005; Brown, 2014; & Christiansen, Baum, & Bass, 2011). In this case, awareness of the sensory stimulation or opportunities of sensory enrichment in an exhibit increases various types of exposure for sensory processing, regulation, and integration skill practice or may prevent those with sensory sensitivities from access or successful and engaging participation. An environment that facilitates this practice changes components of the occupations, as well, requiring occupants of the space to adapt their methods and performance. The anticipated response to the innovative exposure transpires into sensory integration and adaptive behaviors. Similarly, the SI frame of reference and Dunns Model of Sensory Processing identify methods to interact with lifes experiences by developing sensory processing skills and the dynamic relation between exposure, person, and occupational performance (Cho, n.d.-a; Cho, n.d.-b; & STAR Institute, n.d.). Environmental exposure, teaching adaptive behaviors, practice, and sensory input and integration promotes improvements in occupational performance due to the ability to interpret and reason through stimuli to foster an appropriate response. Sensory stimuli alter our life experiences, making this development crucial (Cho, n.d.-a; Cho, n.d.-b; & STAR Institute, n.d.). The most common areas of sensory processing difficulties involve tactile touch, proprioceptive body movement, and vestibular body position input, all of which must occur for an individual to function within occupations (Cho, n.d.-b). The PEOP model, Dunns Model of Sensory Processing, and the SI frame of reference bolster these claims in terms of motivation, skill development, an enabling environment, occupation-based intervention, and sensory-related focus (Bass, Baum, & Christiansen, 2017; Baum & Christiansen, 2005; Brown, 2014; Cho, n.d.-a; Christiansen, Baum, & Bass, 2011; & STAR Institute, n.d.). Therefore, combining these theoretical foundations, TCM remains interested in the skill development and educational opportunities, as well as barriers to access and participation, for children in a fun environment in which their main occupations occur. Therefore, the museum actively engages a population at-risk for developing sensory problems by incorporating sensory stimuli into exhibits and making efforts to notify visitors with various needs of these features for visit preparation. Project Sensory stimuli are difficult to quantify individually, and what someone qualifies as loud or overwhelming or calm varies per person. Additionally, for exhibit development, exhibit teams are estimating what types of interactive opportunities exist, and how many stimuli are present. With collaboration of the exhibit teams, and consulting with outside sources for feedback about use, interest, success, accessibility, and any other topics to navigate decision-making, as indicated, exhibit developers and designers chose which, what, and how to incorporate elements into the exhibit. Therefore, with an ambitious goal of being accessible, inclusive, educational, and experiential, TCM looks for better ways to evaluate designs and spaces and ways to make adjustments for standard operating and sensory-friendly modes, when applicable. Considerations What should a sensory tool(s) that evaluate(s) the accessibility of an exhibit incorporate? The project began with the consideration of making an assessment tool to identify sensory characteristics. Originally, I intended to make one assessment tool that could evaluate any environment for sensory characteristics and quantify them. I labeled this original project the Sensory-Environment Assessment Tool (SEAT). On this basis, I wanted this tool to be userfriendly for any person to utilize, such as an organization, an OT, or a parent, in any space that might present any barriers to access or occupational performance. Upon my first independent trial, a second collaborative trial of the broad assessment tool, and discussion with other professionals and the museum, a more site-specific quantitative perspective was considered to be more feasible for research means. Additionally, museum advisors and exhibit teams requested the option for a simplified qualitative tool, anticipated to be more heavily utilized by the exhibit teams. Ideally, I expected the tools to be efficient and require minimal training, as well as provide multi-use options; this included the idea of only evaluating one sense, one exhibit area, or perhaps one interactive, as indicated by the evaluators interests. As designed by TCM in their sensory signage and maps, some senses were combined; therefore, I reflected this to place proprioceptive and vestibular elements into a section labeled movement. Each tool should be user-friendly for museum personnel to read the manual and complete the evaluations, any other criteria involved in the design elements may be contrived from clinical experiences and museum initiatives. Design of the Quantitative Tool For a quantitative measure, teams might benefit from further development, such as ranking elements of the characteristics based on how stimulating they are as a general population might interpret them, and then formulating a general consensus of what that means or a broad interpretation. First, I studied the Child and Adult/Adolescent Sensory Profile 2 for formatting and general aspects of content that can be characteristic of an environment. Then, I formed a base model for the tool. The assessment tool should consider each sense individually, since not every environment has all the senses receiving input, and they should be specific to museum immersive exhibit opportunities. If a stimulus is not present, it should not be considered in the scoring. The tools should be supported by research as much as possible; however, due to the lack of formal research covering specifics of this topic or how to quantify levels of stimulation, clinical reasoning, experience, expert opinions, and case studies may aide in this aspect. The content in each section needs to be as detailed as possible with clear differences, with examples to aide in decision-making. The process for use should be concise, but thorough, and the format should be available to be printed and online, if possible. Additionally, feedback from trial testing and other related reports from advisors and families who visit TCM may be used to revise and appropriately distinguish differences between levels of classification. The tools should also consider the weight of descriptive choices and ranking, as some aspects of stimuli are more noxious than others, such as very loud, startling noises or ability to navigate a pathway. Lastly, the tool should evaluate an exhibit during typical activity or standard operating modes, but may be used to assess different modes. This measure was labeled the Museum Sensory-Environment Assessment Tool (MSEAT), with an assessment form like a spreadsheet, a scoring sheet, and a manual. For each sense, characteristics of that sense are listed in rows with ranked descriptive choices increasing in broad stimulation progression. An evaluator will determine whether each characteristic is present or not present in the exhibit, and if it is present, select the best matching choice describing its features. Afterwards, the evaluator would score the sensory section based on the weight of the stimulation and identify where it falls into scoring ranges for that sense. Design for the Qualitative Tool For the exhibit teams purpose using the qualitative measure, evaluators desired a onepage checklist of independent sensory and accessibility characteristics to quickly assess the overview of an exhibit, exhibit area, or an interactive. In partnering this tool for sensory stimulation and accessibility and use by the exhibit teams, we chose a non-scoring or interpretation approach, so that exhibit teams may collaborate to interpret the sensory features marked present and determine if the results met expectations or if they might consider adjustments. Making one for an exhibit assessment and one for interactives, I labeled these as the exhibit and interactive accessibility, sensory, and inclusion (ASI) appraisals. For the interactive ASI appraisal, I identified several characteristics that key or highlighted interactives are recommended to possess, based on museum initiatives, experience, evidence, and visitor feedback. Likewise, I created a manual for this assessment option. Implementation of the M-SEAT Beginning with the original SEAT, my TCM mentors and I each individually trialed the tool in a known problematic exhibit space. Between the three users, we all chose the same descriptive choices on seven of the forty-one characteristics (17%), and two of the three evaluators agreed on average about fourteen times (34%). We all met in the space and discussed the results, noting possible issues might include that I had observed during a slightly different operating mode, one evaluator frequently did not choose only one answer, and the tool seemed to be attempting to capture too many variables that did not pose attributes easily recognizable for a museum exhibit. Following this discussion, I determined to narrow the tool for museum exhibits as the setting and museum staff as users, as it was expected to resolve some issues. Following the revolution to a museum-specific tool, we individually trialed the first draft of the M-SEAT in a well-established exhibit without known problems on the same afternoon. This strategy was used to minimize environmental changes between evaluator trials. Results of this trial attempt produced the following: all three evaluators matched on 40% (15/37) characteristics and two of the three evaluators matching about 56% of the time (20.7/37) on average. Each section classification for each evaluator was assessed, and all evaluators scored into the same category of low, moderate, or high stimulation for three of the four sensory sections assessed (olfactory omitted). In the visual section, individual answers varied, but we each totaled to 18. One evaluator frequently scored higher than others in three of the four categories, as well. Following discussion, I initiated revisions for clarifying descriptions between choices, defining what movement and tactile meant, and instructions when stuck between two choices. Additionally, due to the extent of content in what is considered visual, I subcategorized visual content to exhibit overall, objects, and labels. On the second trial of the M-SEAT, we revisited the same exhibit to compare trial one from trial two with the noted revisions. Additionally, we had collectively been in the assessed exhibit together identifying sensory elements, then completed the assessment individually at a later time. All three evaluators matched on 70% (26/37) characteristics and two of the three evaluators matched choices 79% of the time (29.5/37) on average. For this trial, all three evaluators chose a different answer on only one characteristic, meaning only one item had no matches. All evaluators exactly matched throughout the auditory section. The score ranges per sensory section were relatively narrow and only one evaluator in one sensory section had scored mildly outside the classifications of the other evaluators. Furthermore, evaluators provided feedback stating that this trial was much faster and seemed easier, and that the suggestions for revisions felt more obvious about what pieces to clarify. For the final trial, all three evaluators individually attempted the third draft at the same time in a sensory immersive exhibit, as to challenge the tool. During the evaluation, we grouped to discuss what was considered an object for the visual section based on the special exhibits content. All three evaluators matched on 57% characteristics (23/40) and two of the three matched on average 40% of the time (17/40). This was the first trial of the olfactory section, which was another reason to assess this exhibit. Lastly, I consistently scored higher on every section, but within narrow scoring ranges as the other evaluators. Evaluator feedback from this trial concluded that there was much less confusion, a mention of getting used to a stimulus the more time spent in the exhibit perhaps rating the choice lower, and only four characteristics with all evaluators choosing different options and not matching. Implementation of the ASI Appraisals First trials involved my TCM mentors and I utilizing the appraisals individually in a designated exhibit and interactive on the same afternoon to minimize outstanding variability. On the exhibit appraisal, all three evaluators checked 12 of the 55 boxes, with 18 extra characteristics also marked by at least one evaluator, resulting in 30/55 marked boxes total. For the interactive appraisal, all three evaluators checked 7 of the 45 boxes, with 6 other boxes checked by at least one evaluator, resulting in 13/45 boxes marked total. This first trial coincided with the first draft of the M-SEAT in the same exhibit on the same afternoon. I revised the appraisals based on feedback and discussion, clarifying meaning of each characteristic item, ensuring independence among characteristics, and considering subcategories similar to that performed in the visual section for the M-SEAT. On the second draft, all evaluators completed the exhibit and interactive appraisals together with discussion on the same exhibit as the first trial, but chose a different interactive within the exhibit. We agreed to mark 28/55 boxes for the exhibit appraisal and 19/42 for the interactive appraisal. We collaborated on revisions regarding more clarifications and adding elements such as Are there any? to some sensory sections to better quantify elements present. For the third and final trial of the ASI appraisals, each evaluator completed the assessment individually, coinciding with the same timing from the same challenging exhibit as the final trial of the M-SEAT. All three evaluators marked 15/56 boxes for the overall exhibit, and 14/56 other boxes were marked by one or two evaluators, resulting in 29/56 total boxes marked. On the interactive appraisal, all three evaluators marked 6/42 boxes, and 8 additional boxes were marked by one or two evaluators, resulting in 14/42 boxes marked overall. Based on discussion, I added boxes for acknowledging if the sensory element was not present with the interactive-related content and whether the interactive would benefit from the addition or if the interactive seemed to function well without it. Project Outcomes For each document (assessment forms, scoring sheet, appraisal forms, and manuals), I requested feedback on the final drafts from both TCM mentors. Following their responses, I completed the revisions for an official final draft of each document. TCM mentors and I, who collectively developed these tools throughout the process, recommend future assessments be performed by multiple evaluators to compare and interpret results, as one persons choices may be slightly subjective or only one perspective based on a moment in the exhibit. Additionally, more experience with an interactive, an exhibit, or the tools being used might influence the results. Overall, the revisions and data supported the preliminary utilization of these foundational tools and consider the average comparison rather than individual points, specifically for the MSEAT. As methods to make broad generalizations, these tools highly elicit increased awareness and consideration for sensory elements within an exhibit and how they might impact access or occupational performance, as this may occur in positive, negative, or neutral means. Summary After creating two separate types of tools, TCM staff voiced interest throughout the development about anticipated use of the tools and how to utilize the information for exhibit design and adjustments. Interested TCM staff received a dissemination lecture in varying degrees based on connection and department regarding the purpose and use of the tools and how to trial them or receive further information. My TCM mentors took responsibility for future distribution of the materials and the intentional use of the tools within an exhibits lifetime, implementing them into the developmental and maintenance protocols. Conclusion Through trial and revision, TCM staff anticipates to utilize these tools to become more aware of their exhibit designs and how it might affect their visitors experiences. Though these tools are foundational, TCM may benefit most from the characteristic descriptions from the MSEAT tool or the ASI Appraisals for planning, post-production, and remedial phases to continuously reflect on sensory elements. Additionally, TCM staff might utilize these tools in combination with prototyping and advisor feedback to coordinate future accommodations or adjustments, such as defining sensory-friendly operating modes, scheduling the timing for various operating modes, event planning, accommodations planning, advertising, and coordinating to advise the sensory signage and maps for exhibit descriptions and visitor planning. In the future, other museums, community attractions, or researchers might benefit from this conceptual movement in evaluating sensory elements within an environment and how they impact the social and physical dynamics for people. More research to support or evaluate this topic could provide more direction for future initiatives in community engagement, accessibility, or skill development. Reference List American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1-S48. Baroncelli, L., Brasche, C., Spolidoro, M., Begenisic, T., Sale, A., & Maffei, L. (2010). Nurturing brain plasticity: Impact of environmental enrichment. Cell Death and Differentiation, 17, 1092. doi:10.1038/cdd.2009.193 Bass, J. D., Baum, C. M., & Christiansen, C. H. (2017). Person-Environment-OccupationPerformance model. In Hinojosa, J., Kramer, P., & Royeen, C. B., Perspectives on human occupations: Theories underlying practice (2nd ed., pp.161-174). F. A. Davis Company. Baum, C., & Christiansen, C. (2005). Person-Environment-Occupation-Performance: An occupation-based framework for practice. In C. Christiansen & C. 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American Journal of Occupational Therapy, 69, 905185050. http://dx.doi.org/10.5014/ajot.2015.016790 Appendix Table of Contents M-SEAT Manual M-SEAT Assessment Form M-SEAT Scoring Sheet ASI Appraisals Manual ASI Appraisal Forms DCE Weekly Planning Guide April 2022 Museum SensoryEnvironment Assessment Tool (M-SEAT) Manual Patia Hunt, OTS University of Indianapolis | OTD May 2022 Ball State University | Exercise Science 2019 Personal Contact Info: patiadh96@gmail.com Developed in partnership with: The Childrens Museum of Indianapolis and University of Indianapolis OVERVIEW The Sensory-Environment Assessment Tool (SEAT) was an original project to build a foundation for an assessment tool to help users evaluate an environment for sensory stimuli. While the SEAT continues to require more work to be broad and encompassing for all environments and user-friendly utilization, the Museum Sensory-Environment Assessment Tool (M-SEAT) was developed as a more specific product to evaluate museum exhibits and their sensory features. In every physical environment, sensory stimuli are present in varying degrees and are often multi-faceted and difficult to isolate. A persons ability to take in and process sensory information determines how they experience life, how they describe a moment, how they emotionally respond, and how they learn or adapt. While some environments are relaxing or natural, others may be adventurous or overstimulating. Since museum exhibits tend to vary across museum types, topics and interaction objectives, sensory stimulation based on exhibit design and programming features tend to vary respectfully. This tool was developed specifically for The Childrens Museum of Indianapolis; however, other childrens museums or interactive museums might benefit from use or consideration of features noted within this tool, as well. Development of the M-SEAT focused on capturing as many sensory features and their varying degrees of stimulation to provide an objective insight into what an exhibit might portray for visitors and how it might compete with potential access or participation to certain populations. For this setting in particular, low and high stimulation does not correlate to positive or negative attributes, but rather an awareness and consideration for how the topic, environment, activities, and exhibit goals and main messages complement one another. An occupational therapy (OT) student designed this tool as a doctoral capstone project to be user-friendly for museum staff, predominantly exhibit developers and designers and those in the research and operations departments, to assess the level and characteristics of sensory stimulation present within an exhibit during the post-production, remedial, and maintenance phases. This tool may be used in individual sensory sections, targeting each sense of interest or as they apply, or as a whole. This may also aid in the creation of a more or less stimulating environment, adjusting what types of stimulation features are present, or how many stimuli are represented. ABOUT THE TOOL THE SENSES Understanding each sense is important to defining what is being evaluated within a given environment. A person utilizes the eight (8) senses to experience the world and interact throughout life (Kranowitz, 2005; Parham & Mailloux, 2020). The five commonly known senses are considered external senses, referring to sensory input retrieved from outside the body: auditory (sound), gustatory (taste), olfactory (smell), tactile (touch), and visual (sight). The less common senses are considered internal due to the stimulation occurring within the body: interoception (internal body awareness like hunger or breathing rate), proprioception (muscle sensations related to body position and movement), and vestibular (head position in space, related to balance). Occupational therapist Jane Ayres jumpstarted research and therapy regarding the senses and sensory integration skill development in the 1970s, establishing the foundation for understanding and addressing sensory experiences and behaviors (Parham & Mailloux, 2020). Scaffolding off her initial work, Winnie Dunn and others specialized in the interest areas of sensory processing and environmental contexts and developed theories and frames of references to utilize for people in the humanities departments, such as OT, to address behavior and development (Parham & Mailloux, 2010). Sensory information is the foundation for lifes interactions. Every day, living things like people, plants, and animals utilize sensory means to gather knowledge and make decisions based on this reciprocal relationship with our environments. We take in sensory information through different means, as described above, process the information to decipher its meaning (threat, educational, experiential), and then react to this information or stimulus (Kranowitz, 2005; & Parham & Mailloux, 2020); then, through time and practice, individuals refine their sensory skills to develop socially appropriate behaviors, such as ignoring noisy neighbors, noticing a body language adjustment during a conversation as if a person is irritated by your response, or primal and learned instincts to threats like fight, flight, or freeze, i.e., evacuating a building during a fire alarm. However, sensory-related skills are refined through life experiences, making individuals unique with their own preferences. Without exposure, practice, education to social constructs, and optimally functioning neurological systems, people may differ in their sensory needs, such as procuring avoidant or seeking behaviors, higher or lower threshold for tolerable sensory stimulation, inappropriate behaviors, and difficulty learning or participating in activities, like social engagement (American Occupational Therapy Association, 2020; Kranowitz, 2005; & Parham & Mailloux, 2020). For these reasons, this tools development promoted the need for those with different educational and employment-based backgrounds to address sensory-specific accessibility features of museum exhibits. For The Childrens Museum of Indianapolis, every exhibit team pairs an exhibits topic and main messages with a target audience and different interactive opportunities to foster a positive, unique learning experience. The main purpose of this tool is to allow for an evaluator, particularly a museum exhibit team member, to characterize an exhibit for multiple levels and types of sensory stimulation. Each aspect of the tool is intended to target people of varying groups within a general population; however, this tool presents broad generalizations. Not all people interact with sensory information the same, which is expected and supported. This tool simply quantifies the sensory information and quantifies it as most people are anticipated to interact with them. Researchers also suggested that sensory exposure to all individuals, regardless of client factors, demonstrated benefits to skill development, and this skill refinement might transfer into other areas of performance, promoting the versatile use of sensory-informed decision making (Blanche et al., 2016; Cahill & Beisbier, 2020; Smart et al., 2018; & Woo & Leon, 2013). Therefore, for an environment that is generally available to the public, sensory stimulation is considered beneficial to skill development, engagement in the experience, and crucial to learning. However, the general public also incorporates outliers who might benefit from more of fewer sensory features or accessibility measures, which frequently interconnect in a dynamic relationship. These all highlight why sensory-specific accessibility should be part of a museum exhibit teams planning and development process. TOOL STRUCTURE Assessment Form Sensory sections: *Olfactory, Auditory, Movement, Tactile, and Visual. *Olfactory is listed first on the M-SEAT tool as the perception may overlooked or altered during the evaluation of other sections. Each sensory section has a list of characteristics (represented as rows) labeled in a lefthanded column. Each characteristic has descriptive choices along the same row. The descriptive choices are listed in a ranked order from 1 (less stimulating) to 5 (very/highly stimulating). Many choices also have examples in parentheses and italics in their corresponding boxes. The visual sensory section has subcategories within it to help isolate different visual content. At the bottom of each section, there are two rows with fill-in boxes for scoring. These rows will produce a space to calculate the raw scores, weighted scores, and total score for each sensory section. Scoring sheet Each sensory section has its own scoring table. Within each scoring table there is a fillin box to place the total sensory section score and the classification the exhibit or exhibit area falls into based on its scoring range. There are also different environment examples per stimulation classification for broad reference. Each sense involved in a sensory section of the M-SEAT is listed below with a general description, reasoning of importance or use, expected reactions, and common populations who might be at-risk for having complications with the sense. Not all senses are listed, as some are often not incorporated into museum exhibits (gustatory - taste) or cannot be objectively-integrated features of an exhibit (interoception - internal body awareness). OLFACTORY Description: Smell; dependent on the nose and respiration; discrimination skills; helps identify or locate environment contents; crucial to components of taste Use: Survival, socialization, engagement, mood, and self-esteem Expectations: Identifying a threat in an area such as a gas leak; provoking interest in food; deterrent; creating an atmosphere or mood; smelling bodily odors relevant to socialization and threats At-Risk: ASD, eating or digestive disorders, migraines, anxieties, trauma, respiratory disorders, allergies, and sensory processing needs (Kranowitz, 2005, pp. 16, 18, & 53; & Parham & Mailloux, 2020). AUDITORY Description: Sound, dependent on intact hearing; can develop discrimination and comprehension skills Use: Communication and socialization; locate stimuli; a primal sense associated with determining threats; processing movement (balance, flexibility, coordination, and vision), respiration, selfesteem, and academic learning Expectations: Turning head toward direction of sounds, reacting to volume, tone, pitch; engaging in communicative or social interactions At-Risk: ASD, ADHD, DD, hearing disabilities, trauma, neurological disorders, vertigo and migraines, anxieties, and sensory processing needs (Healthwise Staff, 2020; Kranowitz, 2005, pp. 16, 18, 53, 176-177, & 186-190; Noise Quest, n.d.; & Parham & Mailloux, 2020). MOVEMENT (PROPRIOCEPTION & VESTIBULAR) Description: Movement and body position; joint compression, muscle contraction or stretch; body parts and head position in space, balance, movement through space, and relation to other body segments; precision, coordination, and efficiency of movement; ability to orient or upright self; ability to detect threats; heavily incorporates vision, hearing, touch, and internal awareness to provide skilled kinesthesia or body awareness and refinement of movements Use: Daily functions, play, socialization, engagement and participation, self-esteem; fine and gross motor skills such as coordination, balance, motor praxis, planning, and control; handwriting, sports and physical activity (heavy work); ability to tolerate different positioning or right oneself Expectations: Engagement in movement opportunities that require varying amounts of total body involvement, intensity, duration, frequency, and skill; leisure activities or hobbies that involve movements opportunities; ability to right self or orient self to environment; willingness to move through environment At-Risk: ASD, CP, DD, ADHD, migraines, anxieties, arthritis, respiratory disorders, neurological disorders, difficulties with sensorimotor or sensory discrimination, mobility deficits, trauma, vision or hearing disabilities, car/movement sickness and vertigo, and retention of primitive reflexes Proprioceptive refers to body movement qualities Vestibular refers most often to head position and balance (Kranowitz, 2005, pp. 54, 113-114, & 136-138; & Parham & Mailloux, 2020) TACTILE Description: Touch, direct contact through the skin across the whole body; of the most predominant senses; input relates to light touch, deep pressure, skin stretch, vibration, movement, temperature from contact (not internal temperature), and pain; discrimination skills Use: Daily functioning as items contact or change components of skin and receptors; provides information for developing skills of interoception and proprioception, visual discrimination, language, academia, emotional security, and socialization Expectations: Exploration through hands most commonly; comfort and preference in textures, temperatures, physical contact; ability to immerse in environments or wear variety of clothing at preferences; means of learning At-Risk: ASD, CP, DD, ADHD, anxiety and phobias, burns, vision disabilities, trauma, neurological disorders, allergies, and sensory processing needs (Kranowitz, 2005, pp. 17, 52, 82-83, 91-101, & 108; & Parham & Mailloux, 2020). VISUAL Description: Sight; any visual content in an environment that can be observed through the eyes; dependent on intact vision and the presence of light (shadows, white & black, colors), acuity and motor skills are separate from sensory skills, such as discrimination, contrast, edges, and movement; plays role in vestibular skills and eye-hand coordination Use: Daily functions interacting with elements of environment, defines space; identify components within a space; ability to defend against threats, guide or direct movement Expectations: Visually scan environments, detect navigation options and items to otherwise interact with, determine distances or qualities of objects or the environment, socialization, leisure, reading and learning At-Risk: ASD, DD, ADD, ADHD, migraines, anxieties, vision disabilities, trauma, neurological disorders, car/movement sickness and vertigo, and sensory processing needs (Archtoolbox, 2021; Hill, 2011; Kranowitz, 2005, pp. 15-16, 18, 53, 155-161, 169-173; Parham & Mailloux, 2020; & Peterson, 2020). CONSIDERATIONS 1. Evidence-based practice, literature, other assessment tools, clinical experience, and staff and visitor feedback at The Childrens Museum of Indianapolis advised the development of this tool and quantifying characteristics stimulation levels. 2. This tool assesses an exhibit and the common visitor expectations of an exhibit, not to assess individual behavior. Data from prior exhibit evaluations and objective general observations may influence some choices, but individual cases should not. 3. This tool does not necessarily incorporate social environment, such as staff members who may have received specific training. However, regular programming is included, such as regular announcements or sound and light programs, as part of the anticipated and physical exhibit characteristics. 4. This tool may be used to assess one exhibit area or the exhibit as a whole. An evaluator is expected to walk about the exhibit or exhibit area when assessing; however, if the exhibit is very large and difficult to assess as a whole (i.e., cannot see outer walls of exhibit from most points within the exhibit, or the exhibit areas may have their own subsections), it would be recommended to assess area by area to compile an overview of the exhibit. 5. This tool may be used to assess various operating modes. The evaluator should comment on the mode setting during assessment and other noteworthy features that may alter the assessment. 6. This tool may be used in sections or as a whole, meaning that not all sections of the assessment may be relevant or of interest for every exhibit or exhibit area being assessed. 7. This tool does not specify that any level of stimulation is good or bad or preferred over another. Rather, the classifications may inform an evaluator of the qualities and quantities of stimulation present, as to perhaps compare the assessment results with design expectations. 8. Descriptive choices may be structured in accumulative, progressive, independent, or interval choices. This is intended to best match characteristic options to exhibit features and takes into account the significance of the sensory stimuli descriptive ranking. For example, in the visual section, the average movement of visuals characteristic has 3 descriptive choices in a gradual, progressive order, but the average ability to navigate characteristic has three interval-like descriptive choices. This indicates that the ability to navigate an exhibit is more essential, stimulating, and/or disorienting than the movement of lights or screens. INSTRUCTIONS This tool may require slight subjective judgment and outside knowledge, such as exhibit target population age range, but objective perspectives are recommended. 1. Get familiar with the M-SEAT materials and each characteristic. An evaluator should be generally aware of which features they should be noting during an assessment. Ideally, more than one evaluator should individually assess an exhibit or interactive using these appraisals to receive multiple versions of feedback. 2. Identify the operating mode and/or visitor expectation (weekday crowd versus peak) to select the best representation of the exhibit needing evaluation. 3. Fill out the header information on the M-SEAT assessment form, noting the exhibit title, operating mode, including crowd or day/time (weekday at 4 PM vs Saturday at 10:30 AM), target age group, date, and evaluator information. 4. Walk through the exhibit or exhibit area with the M-SEAT assessment form in hand. Make notes in the designated sideline boxes as appropriate; list the interactives, any audio present, the objects/structures, lighting, etc. 5. Begin filling out the assessment form: a. First, identify whether the characteristic is present or not present within the exhibit environment. Place an X in the coordinating box. If the characteristic is not present, move to the next row (next characteristic); do not select a ranked choice for a characteristic that is not present. If the characteristic is present, proceed to the next step (b.). If unsure, read the descriptive choices provided along the same row. If the exhibit environment does not match any components listed, the characteristic is likely not present. b. A characteristic that is present requires a ranking. Along the same row as the characteristic, read the descriptive choices provided and choose one descriptive choice/box that best matches the stimulus of the exhibit. Mark the best matching descriptive by circling, marking with an X, or highlighting your selected choice. i. For many items, the characteristic defines an average of any features that are present. If stuck between two options, choose the option that best describes the average or overall state of the exhibit, or the ranking number that best seems to match the characteristics stimulation level (1 being less stimulating, 5 being highly stimulating). Avoid the impulse to allow one time outliers to influence decisionmaking; consider the most common or appropriate stimulation level. c. Repeat a. and b. through all characteristics for each section being assessed, identifying them as not present or as present and associated with a descriptive ranking choice. SCORING Two rows at the bottom of each sensory section on the assessment form are designated for scoring purposes. These identify how many characteristics are present in the assessed environment and how stimulating the sensory features are for each section. Each section completed will result in a total score for that sensory element. The scoring sheet is used for interpreting the classifications for each section. On the assessment form: 1. Calculate the characteristics present. Sum the total number of characteristics marked as present and write the number into the corresponding box for each sensory section assessed. 2. Calculate the raw scores per column. For each ranking column (labeled 15), count how many descriptive choices were chosen and write that number into the first row of scoring boxes to determine how many characteristic descriptive choices were selected per stimulation ranking. 3. Calculate the weighted scores by column. Per column, multiply the raw score (numbers from step 2) by the number indicated by the column (as instructed in the next row of boxes under the raw scores, e.g., Multiple above score x2). Write the weighted score in these boxes per column. 4. Sum the weighted scores for a total score per sensory section. Add each weighted score (from step 3) together for a total score and write this number into the corresponding box to the left. On the scoring sheet: 5. Transfer the total scores for each sensory section on the assessment form to the corresponding boxes on the scoring sheet. 6. Identify the classification per sensory section using the score ranges. Write the identified classification in the corresponding box at the top of each section. Interpretation Based on the environment assessed, these classifications may resemble comparisons to other settings and likewise may promote consideration for types of activities that occur in such settings. These are not indicative of all environments and should be used as a general reference. Based on the interpretation, evaluators may recommend adjustments to the environment to better suit the target audiences, activities to be performed in these spaces, and goals or objectives of the exhibit or experience. Low stimulation This environment is comprised of few, simple, and/or calming stimuli demonstrating consistency. This environment is often proposed for activities requiring focused, sustained attention, reducing stress, or leisure activities. This level of stimulation tends to be associated with sensory-reduced or sensory friendly environments. Another way to consider this is having a less stimulating passive environment, such as lighting and audio, with some voluntary active stimulation through movement, tactile opportunities, or choice participation such as pressing buttons that provide sensory feedback. Moderate stimulation This environment is an ideal compromise for most activities and audiences as an overall just-right challenge for general population seeking engagement, such as community attractions. Low-moderate mixtures of sensory stimuli is most recommended for exposure and practice for general population or those with minor sensitivities; for this purpose, it is most beneficial when an exhibit has a variety of sensory stimulation types and levels that match the interactive activities and exhibit main messages. High stimulation This environment may aid in the development or advancement of sensory skills like self-regulation and processing given this stimulation scenario. This environment is not ideal for those with sensory sensitivities, and may be considered overwhelming and more difficult to attend to details. This level of stimulation may also be advertised as an immersive experience. However, those with low registration or sensory seeking needs may benefit from the varying amounts of sensory stimulation and opportunities for engagement. If the classification does not meet previous expectations, such as being ill-matched with the target audiences, activities or interactive opportunities, or exhibit goals, evaluators and exhibit teams are recommended to reflect on the characteristic descriptive choices from the assessment form to alter the exhibits or exhibit areas sensory stimuli to more or less stimulating options, as the assessment form may elicit a progressive gradient. Generally speaking, if an individual or group has a sensitivity to sensory stimulation or a specific type of sensory stimulation, a lower amount of that stimulation is recommended. (i.e., lowering bright lights, swapping out bright colors and visuals, reducing loud or highly contrasting sounds) For a group with seeking behaviors or low registration, more stimulating opportunities is recommended to meet or fulfill the higher input thresholds. (i.e., providing more movement opportunities, louder sounds or greater sound variations, brighter colors and more engaging or complex visuals) For mixed groups or the general population, it may be recommended to vary the sensory types and levels of stimulation across the exhibit to provide holistic exposure and engagement, especially for children. One way to tend to both audiences of seeking and sensitivities is to tend to those with sensitivities in the passive environmental features, such as dimming lights and modifying or reducing sounds, and tend to those with seeking needs in the active or voluntary methods, such as many differing movement or interactive opportunities. (i.e., chances to press buttons to receive auditory or visual feedback for seekers) If one sense is impaired, a person may have more advanced skills in other areas to fulfill the experience through other means. (i.e., someone who is blind may have more advanced hearing skills, rely on audio descriptions, or seek more opportunities through tactile opportunities, like ridging on objects or vibrations.) (Blanche et al., 2016; Bodison & Parham, 2010; Clarke & Hasse, n.d.; Dunn, 2007; Kranowitz, 2005; Lussenhop, et al., 2016; Parham & Mailloux, 2010; Parham & Mailloux, 2020; & Silverman & Tyszka, 2017) Acknowledgements I would like to thank the following for their contributions to this project. University of Indianapolis Dr. Taylor McGann | Assistant Professor for providing the OT and university and capstone requirement lens and being primary investigator/capstone advisor for this experience and project. Dr. Christine Kroll | Assistant Professor and Occupational Therapy Doctoral Capstone Coordinator for helping form the foundation of the project prior to the doctoral capstone experience. The Childrens Museum of Indianapolis Betsy Lynn | Operations Project Manager and Accessibility Coordinator Susan Foutz | Director of Research and Evaluation for being the primary forces to assist the shaping and trialing of the original SEAT and M-SEAT through its developmental phases. Tim Scully | Intern Program Manager Exhibit Core Teams, Research and Evaluations department, Operations department, and other associated staff and partners for supporting this project, consistently requesting or integrating accessibility concepts into planning and maintenance phases of exhibits, and interest in final products and utility for future museum implementation. On behalf of The Childrens Museum of Indianapolis as IMLS grant advisors: Roger Ideishi | Program Director of Occupational Therapy and Professor of Health, Human Function, and Rehabilitation Sciences | The George Washington University Leigh Ann Mesiti Caulfield | Strategy and Communication Manager for the Learning & Research Division | Museum of Science, Boston for meeting with Betsy, Susan, and myself to discuss utility, accessibility, and other logistics for tool development. Reference List American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), advance online publication. https://www.aota.org/~/media/Corporate/Files/Secure/Practice/OfficialDocs/Guid elines/OTPF4_FINAL_for_web.pdf Archtoolbox. (2021). Recommended Lighting Levels in Buildings. Retrieved on Feb. 10, 2022, from https://www.archtoolbox.com/materialssystems/electrical/recommended-lighting-levels-in-buildings.html Blanche, E. I., Chang, M. C., Gutierrez, J., & Gunter, J. S. (2016). Effectiveness of a sensory-enriched Early Intervention group program with children with developmental disabilities. American Journal of Occupational Therapy, 70, 7005220010. https://doi.org/10.5014/ajot.2016.018481 Bodison, S. C., & Parham, L. D. (2018). Specific sensory techniques and sensory environmental modifications for children and youth with sensory integration difficulties: A systematic review. American Journal of Occupational Therapy, 72, 7201190040. http://dx.doi.org/10.5014/ajot.2018.029413 Cahill, S. M., & Beisbier, S. (2020). Practice Guidelines Occupational therapy practice guidelines for children and youth ages 5-21 years. American Journal of Occupational Therapy, 74(4), 7404397010. https://doi.org/10.5014/ajot.2020.744001 Clarke, B., & Hasse, K. (n.d.) Benefits of Sensory Rooms. The Sensory Center. Retrieved on Jan 27, 2022, from https://thesensorycenter.com/benefits/ Dunn, W. (2007). Supporting children to participate successfully in everyday life by using sensory processing knowledge. Infants & Young Children, 20(2), 84-101. doi: 10.1097/01.IYC.0000264477.05076.5d Hill, M. (2011). Young children and their perception of colour: An exploratory study (Bachelor's thesis, Avondale College, Cooranbong, Australia). Retrieved from https://research.avondale.edu.au/theses_bachelor_honours/59/ Healthwise Staff. (2020). Harmful noise levels. University of Michigan Health: Michigan Medicine. Retrieved on Jan. 25, 2022, from https://www.uofmhealth.org/healthlibrary/tf4173 Kranowitz, C. S. (2005). The Out-of-Sync Child. Skylight Press. Lussenhop, A., Mesiti, L. A., Cohn, E. S., Orsmond, G. I., Goss, J., Reich, C., Osipow, A., Pirri, K., & Lindgren-Streicher, A. (2016). Social participation of families with children with autism spectrum disorder in a science museum. Museums & Social Issues, 11(2), 122-137. https://doi.org/10.1080/15596893.2016.1214806 Noise Quest. (n.d.) Noise Basics. Retrieved on Jan. 21, 2021, from https://www.noisequest.psu.edu/noisebasics-basics.html Parham, L. D., & Mailloux, Z. (2010). Sensory Integration. In J. Case-Smith, & J. C. OBrien (Eds.), Occupational Therapy for Children (6th ed., pp. 325-372). Elsevier Incorporated. Parham, L. D., & Mailloux, Z. (2020.) Sensory Integration. In J. C. O'Brien, & H. Kuhaneck (Eds.), Case-Smith's Occupational Therapy for Children and Adolescents (8th ed., pp. 516-549). Elsevier Incorporated. Peterson, N. (2020). Recommended Foot Candle Chart. LED Lighting Supply. Retrieved on Feb. 10, 2022, from https://www.ledlightingsupply.com/blog/recommendedfoot-candle-chart Silverman, F., & Tyszka, A. C. (2017). Supporting participation for children with sensory processing needs and their families: Community-based action research. American Journal of Occupational Therapy, 71(4), 1-9. doi:10.1054/ajot.2017.711004 Smart, E., Edwards, B., Kingsnorth, S., Sheffe, S., Curran, C. J., Pinto, M., Crossman, S., & King, G. (2018). Creating an inclusive leisure space: Strategies used to engage children with and without disabilities in the arts-mediated program Spiral Garden. Disabilities and Rehabilitation, 40(2), 199-207. doi: 10.1080/09638288.2016.1250122 Woo, C. C., & Leon, M. (2013). Environmental enrichment as an effective treatment for autism: A randomized controlled trial. Behavioral Neuroscience, 127(4), 487-97. doi: 10.1037/a0033010 Exhibit: Target Age Group for Exhibit: Mode/Details (standard, sensory-friendly, weekday, peak, special event, program setting) : Date: Evaluator Name: Credentials/Title: 1. For each charactertistic, place an X in the corresponding box regarding whether it is present or not present in the space being evaluated. 2. If the characteristic is present, choose one (1) descriptive choice per characteristic to define the stimulus in the space. Mark the best matching descriptive (circle, mark with an X, or highlight one box per row). If stuck between two options, choose the option that best describes the average or overall content, or the ranking number that best seems to match the characteristic in the environment. (Examples are noted in italics in parentheses under the ranked descriptions.) Characteristics OLFACTORY Exists in Environment NOT Present; present (rank) Classification Descriptives 1 2 1. Strength Mild scent (light, some may not recognize; environmental) 2. Familiarity Daily, typical (cleaning, natural smells, food) 3. Range of scent Distinct when near source Scoring Transfer olfactory score to scoring sheet (box B6 ) AUDITORY 1. Directional 2. Sound bleed and competing sounds 3. Volume 4. Type of noise stimulus Moderate; distinct (most will notice the presence of a scent; air freshner in a bathroom; may seem unnoticeable after spending time in space) New, unfamiliar (experimenting chemicals, oddities) Notable within intentional exhibit space; some-moderate range from source 3 Strong; multiple smells; smell may not seem unnoticeable regardless of time spent in space (may be considered headache inducing for some, perfumes or strong candles) * would recommend minimizing or removing this level of stimulus Notable throughout exhibit; may be smelled at entrances/exits NOTES: 4 Notable from outside exhibit or in neighboring areas _________/3 characteristics present ______/3 ______/3 ______/2 _____/1 Total score for olfactory: Multiply above score x1 Multiply above score x2 Multiply above score x3 Multiply above score x4 __________ (0-9) Sum of weighted scores __________ (0-3) __________ (0-6) __________ (0-6) __________ (0-4) 1 2 NOT present Present, (rank) 3 Directional sounds; more dramatic changes; large mix of directional, surround, and audio points like interactives Person or one-point of sound (alternates positioning of sound production output; multiple sounds from (audio from an interactive point or Surround sound or overhead varying directions or overlapping an up-close program) (ambient modes, mic'd programs ) corssover from interactives) indiscernable overlapping sounds 2 sounds, minimal overlap; 2-3 sounds moderate overlapping from within or outside the exhibit, (one sound within the exhibit, the noted while in exhibit difficult to focus attention to other externally; or music/ambient (from within or outside exhibit, isolate on one, distracting overhead with a nearby audio interactive audio is (may have sound bleed within interactive) louder/highlighted) exhibit and from external) Low/Quiet (leaves rustling, whisper ~30dB Fluctuates or conversational library, soft radio broadcast ~30- ('quieter' on slow days, Moderate 40dB small conversations, talking at 3 (average exhibit crowd and average home noise 40dB) feet) exhibit noise) Programming or multiple Slightly more intense noises in interactives provide fluctuating background noise, or moderate levels of noise crowd noise May have minor startle or radio (may also include constant signal-like elements Constant, background, ambient ambient noise with additions of (may also include lower (birds chirping, fans, white noise) other types of noise) descriptive qualities) 4 Loud (higher crowd noise, event arenas, alike a busy office, automatic hand dryer or toilets) Sudden, alerting (thunder, sirens, balloons popping may be in addition to lower descriptive qualities) 5 Exceptional (peak and peak+ noise, theater or programming sound effects) NOTES: Familiar; daily; with purpose; timely; occassionally present (providing instructions at pace pairs with other mild stimuli, i.e. visuals, programming activities) <30 seconds (pronounciations or instruments, announcements, news broadcast ) 5. Purposeful, anticipated familiarity (more than ambient or overhead songs) 6. Average audio duration from interactives or programs 30 secs - 2 mins (interactives, Up-Close programs) Has a few elements that may be considered higher pitch or noxious/ an irritant, otherwise, mostly lower/standard tones Low to treble/moderate (various instruments, nature with (bass, subtle nature, most bugs and birds, audio with some speaking tones, most fans) low-moderate sound effects) Understandable to target Minor discrepancies in sound audience clarity; slight differentiations of (matches accent or ennunciations instructions (<25% of reduced of audience spoken clarity) universal "return to main menu" (mostly clear with a few points of option; reading full instructions; mumble or other noise that may consistent) lead to confusion) 7. Pitch of purposeful audios, operating modes, interactives (higher or lower tones; contrasting noises) 8. Clarity of spoken words via recording or presenter in announcements or interactives Scoring Transfer auditory score to scoring sheet (box B13 ) MOVEMENT #1 pertains to fine motor movement. All others pertain to gross motor movement. 1. Different types and skill/complexity of fine motor movement opportunities 2. Different types of gross motor movement opportunities Respectfully familiar; recognizable or associative in nature to items in movies or daily activities (audio recording with time period, culture-specific, or situationGrossly new; unfamiliar specific elements, education (dinosaur roars, new instruments topics covered in school) or languages) 2:30 - 5 mins (AI or short S&L shows) 5 - 20 mins (longer shows or activity programs) Highly varied between pitches, fluctuates (birds chriping, some higher pitched sound effects like dings) Constant high (metallic, automatic dryers, bird songs or whistles) > 20 minutes (theater shows) Clarity varies between 25-40% of audio content (pronounced accents or content muttled via radio static noise) _________/8 characteristics present Total score for auditory: ______/8 Multiply above score x1 ______/8 Multiply above score x2 ______/8 Multiply above score x3 ______/4 Multiply above score x4 ______/2 Multiply above score x5 __________ (0-30) Sum of weighted scores __________ (0-8) __________ (0-16) __________ (0-24) __________ (0-16) __________ (0-10) NOT present Present, (rank) 1 Simple handwriting skills; ageappropraite for target audience (tracing, writing, drawing, or coloring) 3. Average gross motor skill required (endurance, coordinaiton, balance, understanding) 1 type of movement acitivty (climbing wall, or cranking gears) Some movement, some balance for minor climbing or surfaces; preschool-aged developmental milestones (nondirectional, free play; interaction with space or objects) 4. Average % body involvement (gross motor) <25% Involvement (one limb, one hand; writing) 5. Average effort required Low force required (rolling a ball, pulling <10lb item across non-friction surface) 2 Some more precision, reaction speed, or dexterity required (putty manipulation, some sculpting; adjusting knobs or small items for specific positioning; may or may not also have handwriting opportunities available) 2 different types of movement activities (imaginary play cooking and operating large levers; building a sizeable puzzle and steering interactive) Multiple options in low-moderate categories (some speed, coordination, balance combination required, climbing around simple playground) Multiple options in low-moderate categories (imaginary/free play) Multiple options in low-moderate categories (body-weight activities like crawling over surfaces) 3 4 5 More advanced fine motor skills like reaction time, speed, precise movements or pressure (painting, precision shading, timed typing; may or may not have components from lower descriptives) 3 options of different activities (balance activity, free play, and dig site) Moderate movement skills; 7-9yo developmental milestones (directional, themed play; shooting basketball activities; agility running, balancing on small or less stable surfaces) 25-50% Involvement (multiple limbs; running; kicking around a soccer ball) Moderate force required (some effort or intensity, jumping jacks, may produce perspiration) 4 options of different activities (maze, rearranging a room or doll house, riding carousel, and crawl 5+ different types of movement spaces) activities Requires some complex or more coordinated movements (scrimmage games, tumbling, althetic advanced skills) Average between moderate-high categories; portions require >50% involvement (basketball scrimmage) Some vigorous movement is predictable (speed of play, resistive or moderate-vigorous work) High coordination; 12yo milestones, advanced skills & complexity (organized sport or instructions; form; competitive; juggling) >50% Involvement (upper and lower body/trunk invovlement; climbing; gymnastics) Vigorous force required (climbing agaisnt gravity, heavy work, results in perspiration or heavy breathing) NOTES: List the different gross motor movement opportunities: 6. Average duration and purpose of movement (average movement interaction per interactives in exhibit, may correlate to success via goal achievement) Voluntary choice of duration or end; most interactives are childdriven interactions without specific stopping points (seconds to a couple minutes; imaginary play) Simple task or common play movement pattern (jumping, common sports, climbing over surfaces; instructed, imaginary, or free play) 7. Average familiarity with movement 8. Vision change 10. C hange in contextual/surface levels 11. Physical coordination and movement along a pathway (passive ride or simulations, or active movement) Scoring Transfer propprioceptive score to scoring sheet (box B20 ) There are no dynamic floor surfaces, rides, or simulations present Some securement or supports (harness, some back or side supports, seatbelt, dual-railings) Most interactives present an endgoal determining success (may take a couple minutes to achieve success and finish task; may also be replayable) New movement patterns; goaloriented (or multiple common movements Between low-moderate categories in a new pattern) Vision reduced; on one or more interactive opportunities (darkened space in environment that elicits vestibular sense resulting in moderate change in head position or feeling of positional movement; airplane simulations) Hearing reduced; on one or more interactive opportunities (muffled by headphones; helmets on racetrack) May be opportunities of large positional changes; jumping/climbing between surfaces of >6" at a time Proceeding up/down ramp or or head changes distance in stairs; incremental surface space moderately changes of lesser heights (<6" at (tilting, rocking; change from lying a time) to standing; see-saw, jump/crash (low balance beam; smaller surfaces, climbing walls or climbing portions, stairs) structures) Mixed; some linear & rotatory, corners or twists and turns Linear, clear, wide (simulated car rides, relay races, (swings, most walking paths, requires some visual wayfinding scrolling screens) and planning) 9. Auditory change 12. Stability options for dynamic floor surfaces or simulations (floor mats, balance or moving surfaces, surfaces that might move underneath your foot, require balance, or a ride with movement or simulations) May have objectives but no specific end goal; some interactives are free play and some have specific end-goals (seconds to a couple minutes; repeatable interactions or replayable; multi-optioned, may have successful tasks leading to an abstract end-goal which may not be achieved) Limited supports; optional use of railing, netting, post, or other hand hold; requires active grasp/activation from participants Complex movements/patterns (requires concentration/memory and practice; asymmetrical jumps) Vision occluded; on one or more interactive opportunities (in space that elicits vestibular sense; darkened spaces on rollercoasters) Significant auditory distractions; headphones with extra or different stimulus; on one or more interactive opportunities (loud music while on rollarcoaster; carnival rides) Rotatory, physical obstacles, narrow winding path (carnival rides, spinning, or mazelike movement through path) Dynamic surface/simulation exists without presence of intentional supports (nearby wall or use of another person) _________/12 characteristics present Total score for movement: ______/10 ______/12 ______/10 ______/6 ______/5 Multiply above score x1 Multiply above score x2 Multiply above score x3 Multiply above score x4 Multiply above score x5 __________ (0-47) Sum of weighted scores __________ (0-10) __________ (0-24) __________ (0-30) __________ (0-24) __________ (0-25) TACTILE Contact with the skin, applies pressure feedback at skin NOT level, temperature felt via skin present Indoors, rather stable 1. Climate climate Present; (rank) 1 Indoors, simulated climates (simulated, i.e. greenhouse, or controlled labs) 2 Outdoors, rather stable climate (i.e. sunny and 70) 3 Outdoors, weather conditions (high wind, rain, cold <50 or hot >85) 4 5 NOTES: List the different tactile opportunities: List the different tactile opportunities: 2. Average % body involvement Felt with hands (clay, climbing hands and feet with shoes on, water table) 3. Average duration of tactile interactions 30 seconds - 1 minute (intentional touch interactions) 4. Average familiarity & comfort of tactile content 5. Number of different material types/tactile opportunities (about the number of different options, not the examples providing the types per box) Commonly interacted with during daily activities (blankets, blocks, stuffed animals, plastic food, chairs, buttons) 1-3 different types (i.e. hard plastic toys for free play and 2 different glass touchscreens = 2 tactile opportunities) Scoring Transfer tactile score to scoring sheet (box B27 ) VISUAL Slightly more immersive, hands + forearms, knees, feet, or face (wearables, climbing over stable surfaces on hands and knees) Tactile input via moving through environment contents; immersive surroundings interact with half or more of the body (malleable surfaces like soft cube pit, ball pit, dig sites) > 5 minutes interacting with tactile elements (interactive station/area with free play) Averaged between moderatehigh; uncommon; often avoided by those with sensitivities or Less common; can be connected sought out by seekers; specific through associations; more interactions or relative to sensitive stimuli concepts like those presented in (adaptive seating, tactile puzzles, movies putty, specific clothing, tactile (heavier weighted items, soft balance disks) cube foam pits, slimy) Extraordinary, very uncommon associations, has not experienced except at museums or like-institutions (dinosaur scale replicas, fossils) Average between 1-3 minutes 3-5 minutes (some family learning, quick play) (dig sites, sculpting) Rather typical but may not be daily; or averaged between lowmoderate (fake grass, slightly weighted items, matted flooring) 4-6 different types (i.e. soft and hard plastic toys, >6 different types stuffed animals, adaptive seating, (sand, hard and soft plastics, and playing on the carpet) wood, water, metals, fabrics) ________/5 characteristics present Total score for tactile: ______/5 Multiply above score x1 ______/4 Multiply above score x2 ______/5 Multiply above score x3 ______/2 Multiply above score x4 ______/2 Multiply above score x5 __________ (0-20) Sum of weighted scores __________ (0-5) __________ (0-8) __________ (0-15) __________ (0-8) __________ (0-10) NOT present Present; (rank) Whole Exhibit Environment Entire visual scene: entry/exit spaces, designated areas, built environment, wall content, objects, lighting, interactives, etc. 1. Lighting 1 Universal design; simple; consistent throughout exhibit (ambient; avoid shadows on labels, halogen lights, workshop activities) 2. Average ability to navigate (visually identify paths or direction; "wayfinding") Spatial openness along paths; commonly easy to navigate (arrows, open visual of path across most of exhibit, open navigation ability) 2 Comfortable mood lighting, mildly changes through exhibit areas (daylight cycles; lower lighting overall or in some spaces of exhibit) 3 Varied lighting across exhibit areas; spotlights; flourescent lights (mild S&L shows, blue lighting) 4 Multi-setting modes; varies from bright and dim lightings (haunted houses, heavy gobos) Most visitors navigate around obstacles while moving through space; may have visual distractions/obstructions (some obstacles in visual path; may have slight confusion on flow or end points through exhibit) Components of both slow and moderate movements (one or two visuals have some moderate speed components, such as faster transitions or scrolling, zooming in or out, or rotatory or cyclic features; otherwise movement of visuals is slow or limited) 3. Average movement of visuals (lights, video screens, simulations) Movement of visuals is slow or limited (scrolling video, consistent slow tracing/path of lights or screens, mild disco ball) 4. Average spatial spread of visuals (structures, displays, objects, interactives) Mixed between standard displays and creative representation of objects or structures in the exhibit Common expectation of setting, (abstract outlines, a wall case relatively open display with curvy, protruding display cases or signs on walls at edges; may otherwise have visible level for target audiences common or standard boxed (cane detection) cases and familiar sizes) Difficult to navigate; multiple narrow pathways or corners; visually obstructed (mazes, crowds) A handful of visuals moving at moderate speed; may be paired/expected with other stimuli (changing colored lights aimed at consistent points, action movie on a screen, stop and go elements, zooming in/out; may also have lower descriptive elements) Some crowding of objects or structures in visual space, visuals may consist of floor to ceiling; multiple structures to navigate; spatial variations (hanging objects, creative display case structures, built across a wall, to ceiling height, or into floor) 5 Highly varied location of visuals at multiple levels; immersive experiences (built-environments like houses you can enter, caves, tunnels) NOTES: 5. Cohesion, clarity, and complexities of visual scene overall Objects Creative structural features, items made be production team, collections items, interactives Bright, happy, or vibrant colors; some patterning, consistent idea, A standard theme, consistent, interconnected theme Small space, simple some mix of colors; generally (design theme, elicits theme/content exhibit, soft or clear how things interconnect and mood/atmosphere, areas simple color palette; simple common smoothly transition or have patterns, visual clarity of content (park, country/state-themed obvious separation between (display cases, workshop spaces, events, easy to understand areas, might require some focus small corner exhibits) painting or mural, all areas match) to identify details) 1 2 7. Familiarity with objects Few structures or objects grouped in same space (display cases or object is along Mixed qualities of lower and wall or as center pieces) moderate descriptions Between associatively common and novel descriptions; free or imaginary play without education would be generally feasible and accurate (some new toys or interactive types mixed with known Objects are generally known or interactive methods; living in easily associated to audience's different culture or time period known objects in daily life that has associative features like (toys, tools, paintings) clothing, games, or artifacts) 8. Average size of objects Common/expected to slightly uncommon; anticipated variations of object/visual sizes (may be proportionally smaller or larger replicas, "life-sized" objects within shared space) 6. Average spatial placement of objects 9. Average lighting on objects Labels Object labels, instructions, interactive labels, donor labels, fun facts, and other signage for the exhibit 10. Location of labels 11. Sign, label, and text legibility 12. Lighting Mixed qualities of lower and moderate descriptions (average between common and uncommon sized items; interactive playhouses) Objects are lit based on Objects are well-lit, without glare, environment (natural light or not distorting visitor's space exhibit light suffices) or to (spotlight does not overcast onto highlight key objects or specific visitor or shine into visitor's eyes) features of an object 1 2 Labels for exhibit are placed at reasonable height for accessible viewing and paired with objects or at entry ways Labels are limited in numbers Labels are moderate in number or while describing necessary placed at varying heights or information disances; labels are sequential 3 Moderate spatial density of objects in display cases or other structure location in exhibit (more intentional effort required to scan & notice each item, multiple structures to navigate through space; slight crowding of objects or structures) Contrasting, mixed colors; vague or overarching theme and patterning; more vague clarity of visual content (abstract art, multiple areas of different topics; different areas are not clearly separated nor have same content/idea) 4 Mixed qualities of moderate and heavier descriptions (a few wall-sized or immersive structures requiring effort to scan; other elements may comprise of lower descriptive qualities) 5 NOTES: Dense grouping of objects in space, requires heavy scanning, items may be missed; immersive elements (floor to ceiling objects or structures, overlapping content, slightly hidden objects) Once in a lifetime experience; immersive or in-person experience/simulation; about 50% of content is novel experience (living in different culture or time period) Varying sizes within an environment, adds to immersive feeling; uncommon; highlight pieces (life-sized dinosaurs; wall-sized murals; carousel, giant snowglobe) Objects are not well-lit to emulate an immersive environment or other context (may be an oversight, or nonspecific piece) 3 Labels are dense or missing, placed in percarious locations which may not be beneficial to most audiences Greatly varied legibility based on fonts, sizes, colors, spatial presence; portion of target audience may identify meaning due to context; anticipate difficulty for some audience members to interact/understand content Varying signage with some legible (language translations, may be and some less legible missing some descriptions; large (some signs are less consistent in presence of hieroglyphics or legibility due to font, size, colors, other language symbols meant spatial presentation) for decoration or decoding) Legible; following universal design; may have simple/consistent visual symbols paired with language (standard/common font size and colors) Labels are well-lit and do not cast shadows or glares; do not reflect back onto visitor; or intentionally Mixture of lighting on labels as lit Label is in dark location, has lit or not lit to match and legible or difficult to read due shadow cast over it, or produces atmosphere/mood to lighting glaring 4 5 NOTES: Scoring Transfer visual score to scoring sheet (box B34 ) _________/12 characteristics present Total score for visual: ______/12 Multiply above score x1 ______/11 Multiply above score x2 ______/12 Multiply above score x3 ______/4 Multiply above score x4 ______/2 Multiply above score x5 __________ (0-43) Sum of weighted scores __________ (0-12) __________ (0-22) __________ (0-36) __________ (0-16) __________ (0-10) Exhibit Label: Target Age Range for Exhibit: Exhibit Mode/Details: Date: Evaluator Name: Credentials/Title: Olfactory Score: Classification Low Stimulation Moderate Stimulation Heavy Stimulation Notes: _________/9 Olfactory Classification: ________________________ Score range Example environments 0-3 outdoors, homes 4-6 stores, homes, restaraunts 7-9 bathroom after using bleach Auditory Score: Classification Low Stimulation Moderate Stimulation Heavy Stimulation Notes: _________/30 Auditory Classification: ________________________ Score range Example environments 0-12 library, park, quiet classroom 13-20 classroom, typical store 21-30 concerts, shows/events Movement Score: Classification Low Stimulation Moderate Stimulation Heavy Stimulation Notes: _________/47 Movement Classification: ________________________ Score range Example environments 0-15 classroom play, free play 16-30 playground, sports 31-47 organized sports, heavy work Tactile Score: Classification Low Stimulation Moderate Stimulation Heavy Stimulation Notes: _________/20 Tactile Classification: ________________________ Score range Example environments 0-6 library, classroom, home 7-13 home, park/playground 14-20 outdoors, events, attractions Visual Score: Classification Low Stimulation Moderate Stimulation Heavy Stimulation Notes: _________/43 Visual Classification: ________________________ Score range Example environments 0-20 natural environments; classrooms; home 21-32 community locations 33-43 museums, concerts April 2022 Exhibit & Interactive Accessibility, Sensory, and Inclusion (ASI) Appraisals Manual Patia Hunt, OTS University of Indianapolis | OTD May 2022 Ball State University | Exercise Science 2019 Personal Contact Info: patiadh96@gmail.com Developed in partnership with: The Childrens Museum of Indianapolis and University of Indianapolis OVERVIEW During the development of the Museum Sensory-Environment Assessment Tool (MSEAT) as a quantitative assessment tool, museum staff and advisors showed interest in a short-and-sweet qualitative assessment measure, one for an exhibit overview and one for individual interactives. The result became one-page appraisals using qualitative descriptions regarding accessibility, sensory, and inclusion (ASI) features that The Childrens Museum of Indianapolis had started identifying as a way to audit exhibit and interactive design and remediation. The appraisals were structured with a checklist-type design of independent features to show what an exhibit or interactive does or does not have as it applies to visitor access and participation. An occupational therapy (OT) student designed this tool as a doctoral capstone project to be user-friendly for museum staff, predominantly exhibit developers and designers and those in the research and operations departments, to assess the level and characteristics of sensory stimulation present within an exhibit during the post-production, remedial, and maintenance phases. This tool may also aid in the creation of a more or less stimulating environment, adjusting what types of stimulation features are present, or how many stimuli are represented. ABOUT THE APPRAISALS THE SENSES Understanding the senses is important to defining what is being evaluated within a given environment. Sensory information is the foundation for lifes interactions. Every day, living things like people, plants, and animals utilize sensory means to gather knowledge and make decisions based on this reciprocal relationship with our environments. We take in sensory information through different means, as described above, process the information to decipher its meaning (threat, educational, experiential), and then react to this information or stimulus (Kranowitz, 2005; & Parham & Mailloux, 2020). A person utilizes the eight (8) senses to experience the world and interact throughout life (Kranowitz, 2005; Parham & Mailloux, 2020). The five commonly known senses are considered external senses, referring to sensory input retrieved from outside the body: auditory (sound), gustatory (taste), olfactory (smell), tactile (touch), and visual (sight). The less common senses are considered internal due to the stimulation occurring within the body: interoception (internal body awareness like hunger or breathing rate), proprioception (muscle sensations related to body position and movement), and vestibular (head position in space, related to balance). Often times, sensory-related features within an environment may bar those with varying needs or disabilities from accessing or participating in activities and experiences. OT and accessibility efforts often advocate for the need for an enabling environment to support the activities that a person participates in, and the museum is a great place for leisure, social participation, education, play, and community engagement (American Occupational Therapy Association, 2020). For these reasons, the ASI appraisals promoted the need for those with different educational and employmentbased backgrounds to address accessibility features, highly motivated by sensory elements, of museum exhibits and interactives. For The Childrens Museum of Indianapolis, every exhibit team pairs an exhibits topic and main messages with a target audience and different interactive opportunities to foster a positive, unique learning experience. The main purpose of the exhibit and interactive ASI appraisals is to allow for an evaluator, particularly a museum exhibit team member, to characterize an exhibit for multiple elements of sensory stimulation. Each component of the appraisals is intended to target people of varying groups within a general population; however, this tool presents broad generalizations of accessibility and inclusion features that might be note-worthy or problematic in a museum exhibit or an interactive opportunity. There is no target number, as the majority of the points are up for evaluator and exhibit team interpretation; however, on the interactive ASI appraisal, some elements are highlighted as recommended features for the big-ticket interactives. Researchers also suggested that sensory exposure to all individuals, regardless of client factors, demonstrated benefits to skill development, and this skill refinement might transfer into other areas of performance, promoting the versatile use of sensory-informed decision making (Blanche et al., 2016; Cahill & Beisbier, 2020; Smart et al., 2018; & Woo & Leon, 2013). Therefore, for an environment that is generally available to the public, sensory stimulation is considered beneficial to skill development, engagement in the experience, and crucial to learning. However, the general public also incorporates outliers who might benefit from more of fewer sensory features or accessibility measures, which frequently interconnect in a dynamic relationship. These all highlight why sensory-specific accessibility should be part of a museum exhibit teams planning and development process. APPRAISAL STRUCTURE AND FEATURES Exhibit ASI Appraisal Sections: Auditory, Visual, Movement, Tactile, and Other. Some sections have subcategories (Auditory, Visual, and Other) Each sensory section has a list of characteristics under their respective columns. Each characteristic should be thought of an independent from the others, although they may seem to overlap. In the Tactile section, there are definitions to aid in comprehension. Interactive ASI Appraisal Sections: Auditory, Visual, Movement, Tactile, and Other. The content structure is almost identical to the exhibit ASI appraisal. Characteristics that are bolded, italicized, and have a double-box feature are recommended features for any highlighted (key or showstopper) interactives. Each sense involved in a section of the ASI appraisals is listed below with a general description, reasoning of importance or use, expected reactions, and common populations who might be at-risk for having complications with the sense. AUDITORY Description: Sound, dependent on intact hearing; can develop discrimination and comprehension skills Use: Communication and socialization; locate stimuli; a primal sense associated with determining threats; processing movement (balance, flexibility, coordination, and vision), respiration, selfesteem, and academic learning Expectations: Turning head toward direction of sounds, reacting to volume, tone, pitch; engaging in communicative or social interactions At-Risk: ASD, ADHD, DD, hearing disabilities, trauma, neurological disorders, vertigo and migraines, anxieties, and sensory processing needs (Healthwise Staff, 2020; Kranowitz, 2005, pp. 16, 18, 53, 176-177, & 186-190; Noise Quest, n.d.; & Parham & Mailloux, 2020). VISUAL Description: Sight; any visual content in an environment that can be observed through the eyes; dependent on intact vision and the presence of light (shadows, white & black, colors), acuity and motor skills are separate from sensory skills, such as discrimination, contrast, edges, and movement; plays role in vestibular skills and eye-hand coordination Use: Daily functions interacting with elements of environment, defines space; identify components within a space; ability to defend against threats, guide or direct movement Expectations: Visually scan environments, detect navigation options and items to otherwise interact with, determine distances or qualities of objects or the environment, socialization, leisure, reading and learning At-Risk: ASD, DD, ADD, ADHD, migraines, anxieties, vision disabilities, trauma, neurological disorders, car/movement sickness and vertigo, and sensory processing needs (Archtoolbox, 2021; Hill, 2011; Kranowitz, 2005, pp. 15-16, 18, 53, 155-161, 169-173; Parham & Mailloux, 2020; & Peterson, 2020). MOVEMENT (PROPRIOCEPTION & VESTIBULAR) Description: Movement and body position; joint compression, muscle contraction or stretch; fine and gross motor skills; heavily incorporates other senses for efficiency of movement Use: Daily functions, self-esteem; fine and gross motor skills such as coordination, balance, motor praxis, planning, and control; ability to tolerate different positioning or right oneself Expectations: Engagement in movement opportunities that require varying amounts of total body involvement, intensity, duration, frequency, and skill; leisure activities or hobbies that involve movements opportunities; ability to right self or orient self to environment; willingness to move through environment At-Risk: ASD, CP, DD, ADHD, migraines, anxieties, arthritis, respiratory disorders, neurological disorders, difficulties with sensorimotor or sensory discrimination, mobility deficits, trauma, vision or hearing disabilities, car/movement sickness and vertigo, and retention of primitive reflexes Proprioceptive refers to body movement qualities Vestibular refers most often to head position and balance (Kranowitz, 2005, pp. 54, 113-114, & 136-138; & Parham & Mailloux, 2020) TACTILE Description: Touch, direct contact through the skin across the whole body; of the most predominant senses; input relates to light touch, deep pressure, skin stretch, vibration, movement, temperature from contact (not internal temperature), and pain; discrimination skills Use: Daily functioning as items contact or change components of skin and receptors; provides information for developing skills of interoception and proprioception, visual discrimination, language, academia, emotional security, and socialization Expectations: Exploration through hands most commonly; comfort and preference in textures, temperatures, physical contact; ability to immerse in environments or wear variety of clothing at preferences; means of learning At-Risk: ASD, CP, DD, ADHD, anxiety and phobias, burns, vision disabilities, trauma, neurological disorders, allergies, and sensory processing needs (Kranowitz, 2005, pp. 17, 52, 82-83, 91-101, & 108; & Parham & Mailloux, 2020). CONSIDERATIONS 1. Evidence-based practice, literature, other assessment tools, clinical experience, and staff and visitor feedback at The Childrens Museum of Indianapolis advised the development of these appraisals for accessibility, sensory features, and inclusion. 2. These appraisals do not necessarily incorporate social environment, such as staff members who may have received specific training, at this time. However, regular programming is included, such as regular announcements or sound and light programs, as part of the anticipated and physical exhibit characteristics. 3. These appraisals may be used to independently of each other, as indicated. An evaluator is expected to walk about the exhibit or interactive area when assessing. 4. When using the exhibit ASI appraisal form, if the exhibit is very large and difficult to assess as a whole (i.e., cannot see outer walls of exhibit from most points within the exhibit, or the exhibit areas may have their own subsections), it is recommended to assess area by area to compile an overview of the exhibit. 5. The exhibit ASI appraisal may be used to assess various operating modes. The evaluator should comment on the mode setting during assessment and other noteworthy features that may alter the assessment. 6. These appraisals are for sole purpose of identifying accessibility, sensory, and inclusion features, not labeling as stimulating or otherwise. The appraisals should only be used as a form of more objective characteristics as part of the exhibit or interactive. Exhibit teams should collectively interpret these characteristics and how they match their expectations, goals, and target audiences. INSTRUCTIONS These appraisals may require slight subjective judgment and outside knowledge, such as what might be considered bright or loud and results from prototyping, but generally objective perspectives are recommended. 1. Get familiar with the ASI appraisal materials and each characteristic. An evaluator should be generally aware of which features they should be noting during an assessment. Ideally, more than one evaluator should individually assess an exhibit or interactive using these appraisals to receive multiple versions of feedback. 2. Identify the operating mode and/or visitor expectation (weekday crowd versus peak) to select the best representation of the exhibit needing evaluation. 3. Fill out the exhibit and/or interactive details on one side of the form, noting the exhibit and/or interactive title(s), operating mode, including crowd level or day/time (weekday at 4 PM vs Saturday at 10:30 AM), target audience age, date, and evaluator information. 4. Walk through the exhibit or interactives area. Participate in the interactive as it has been designed to and/or how a visitor would be anticipated to. 5. Fill out the appraisal form(s). Check or mark the boxes adjacent to each characteristic if the description matches the exhibit or interactive features. Select all that apply. Complete only one appraisal at a time. For the exhibit ASI appraisal, consider changing locations within the exhibit while completing the form. a. Each item is independent from others. If there are some instances that have few text labels and some with moderate text labels, check both and write notes/evidence. b. Remember to consider the subcategories under each section, i.e., exhibit overall, interactives on average, Are there any? 6. Collaborate results with other team members to determine if there are any actions the team would like to take. Acknowledgements I would like to thank the following for their contributions to this project. University of Indianapolis Dr. Taylor McGann | Assistant Professor for providing the OT and university and capstone requirement lens and being primary investigator/capstone advisor for this experience and project. Dr. Christine Kroll | Assistant Professor and Occupational Therapy Doctoral Capstone Coordinator for helping form the foundation of the project prior to the doctoral capstone experience. The Childrens Museum of Indianapolis Betsy Lynn | Operations Project Manager and Accessibility Coordinator Susan Foutz | Director of Research and Evaluation for being the primary forces to assist the shaping and trialing of the original SEAT and M-SEAT through its developmental phases. Tim Scully | Intern Program Manager Exhibit Core Teams, Research and Evaluations department, Operations department, and other associated staff and partners for supporting this project, consistently requesting or integrating accessibility concepts into planning and maintenance phases of exhibits, and interest in final products and utility for future museum implementation. On behalf of The Childrens Museum of Indianapolis as IMLS grant advisors: Roger Ideishi | Program Director of Occupational Therapy and Professor of Health, Human Function, and Rehabilitation Sciences | The George Washington University Leigh Ann Mesiti Caulfield | Strategy and Communication Manager for the Learning & Research Division | Museum of Science, Boston for meeting with Betsy, Susan, and myself to discuss utility, accessibility, and other logistics for tool development. Reference List American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), advance online publication. https://www.aota.org/~/media/Corporate/Files/Secure/Practice/OfficialDocs/Guid elines/OTPF4_FINAL_for_web.pdf Archtoolbox. (2021). Recommended Lighting Levels in Buildings. Retrieved on Feb. 10, 2022, from https://www.archtoolbox.com/materialssystems/electrical/recommended-lighting-levels-in-buildings.html Blanche, E. I., Chang, M. C., Gutierrez, J., & Gunter, J. S. (2016). Effectiveness of a sensory-enriched Early Intervention group program with children with developmental disabilities. American Journal of Occupational Therapy, 70, 7005220010. https://doi.org/10.5014/ajot.2016.018481 Cahill, S. M., & Beisbier, S. (2020). Practice Guidelines Occupational therapy practice guidelines for children and youth ages 5-21 years. American Journal of Occupational Therapy, 74(4), 7404397010. https://doi.org/10.5014/ajot.2020.744001 Hill, M. (2011). Young children and their perception of colour: An exploratory study (Bachelor's thesis, Avondale College, Cooranbong, Australia). Retrieved from https://research.avondale.edu.au/theses_bachelor_honours/59/ Healthwise Staff. (2020). Harmful noise levels. University of Michigan Health: Michigan Medicine. Retrieved on Jan. 25, 2022, from https://www.uofmhealth.org/healthlibrary/tf4173 Kranowitz, C. S. (2005). The Out-of-Sync Child. Skylight Press. Noise Quest. (n.d.) Noise Basics. Retrieved on Jan. 21, 2021, from https://www.noisequest.psu.edu/noisebasics-basics.html Parham, L. D., & Mailloux, Z. (2020.) Sensory Integration. In J. C. O'Brien, & H. Kuhaneck (Eds.), Case-Smith's Occupational Therapy for Children and Adolescents (8th ed., pp. 516-549). Elsevier Incorporated. Peterson, N. (2020). Recommended Foot Candle Chart. LED Lighting Supply. Retrieved on Feb. 10, 2022, from https://www.ledlightingsupply.com/blog/recommendedfoot-candle-chart Smart, E., Edwards, B., Kingsnorth, S., Sheffe, S., Curran, C. J., Pinto, M., Crossman, S., & King, G. (2018). Creating an inclusive leisure space: Strategies used to engage children with and without disabilities in the arts-mediated program Spiral Garden. Disabilities and Rehabilitation, 40(2), 199-207. doi: 10.1080/09638288.2016.1250122 Woo, C. C., & Leon, M. (2013). Environmental enrichment as an effective treatment for autism: A randomized controlled trial. Behavioral Neuroscience, 127(4), 487-97. doi: 10.1037/a0033010 Exhibit Appraisal Post-Production Exhibit: ________________________________________________________ Date: _______________ Operating Mode: _________________________________________________________________________ Target Audience Age: _____________________________ Evaluator: _______________________________ Credentials/Title: ________________________________ Notes: SELECT ALL THAT APPLY to the exhibit/space as a whole (comment why you checked boxes if some seem contradictory; aka most were __, a few were __): Auditory Exhibit Overall Visual Exhibit Overall Times of loud audio during shows, music, or interactives Area has low or dimmed lighting, follows a subtle color palette, or softer tones of light Audio in overall exhibit has startling features Substantial ighting changes across area and/or multiple variants of color scheme Frequent contrasting sounds in pitch or competing tones of sounds Expected to be a louder area on busy/crowded days Audio consists of lower or softer sounds, relatively quiet or natural About half or more of exhibit space has noted sound-bleed from outside exhibit About half or more of exhibit space has noted sound-bleed within exhibit Interactives On Average Interactives do not have audio (N/A) Audio consists of clear voice recording Audio consists of varying accents (compared to proximal geographic region), radio static, or other elements that may alter understanding or clarity Instructions are provided in a clear, concise manner with good timing in sizable chunks Audio has multiple features, such as voices, nature, and sound effects Area has bright lights and bright colors Lighting or other visuals (screens) have fast movement or flashing elements Videos or spotlights project notable light or shadows into viewing space Natural light present Structures or Objects Object theme is consistent throughout space Object types, sizes, and locations/placements vary greatly Scenes, structures, or objects are generally easy to scan Scenes, structures, or objects require some focus to notice details Scenes, structures, or objects are heavy on details and require keen attention Labels Few signs or labels per square footage with minimal detail Movement ARE THERE ANY...? Other Accessibility, Sensory, & Inclusion Fine motor activities (such as drawing with utensils, sculpting, manipulation) Braille present on major labels or signs (titles, start) Gross motor activities that are replicable of a general sport or ordinary movement Braille present on informative texts Gross motor activities that require advanced skills or greater participation or force Ability to operate (buttons, levers, slides) or navigate (move objects through space) Opportunity to passively ride or moderately change position in (interactives) (i.e. tiltable chairs) Opportunity to climb over moderately difficult surface, climb up a 5ft + wall, or climb into (over a ledge, etc.) Tactile Touchables that present as supplementative or a new learning opportunity and conveys information ARE THERE ANY...? Educational touchables that can be manipulated with the hands (clay, dolls, etc.) Educational touchable objects that are fixed in position (bronze dino) Touchables that are 'loose parts' (toy trains, dolls) and add to the educational experience or free play Other languages are represented (Greek, hieroglyphics, Spanish) Different populations are represented (disabilities, ethnicities, genders, religion or politics) Audio descriptions are available Scripts, text, or captioning is readily, consistently available Sensory signage is present upon entering Purposeful/intentional added smells (room freshner, simulated foods, swampy) Interactives provide immediate feedback (audio/visual triggered, etc.) Most interactive(s) have obvious affordance from a visitor's perspective, or their presence suggests that there is an interactive opportunity Multiple interactives provide multisensory content delivery opportunities (3+ paired: audio, visual, text, tactile, and/or movement) Main messages for exhibit learning are presented repeatedly Environmental Moderate text, signs, or labels per shared space that may require additional reading time Objects are weighted Raised outlines/tactile edges Environmental smells (cleaners, chlorine, food where food is present) Large amount(s) of text, signs, or labels that require longer stops for reading Temperature-altered (cold or warm) Area is accessible (ramps, railings, ADA and universal design width/reach) Instructions are visually provided in a clear manner, adequate sized portions, and good timing Wearables (clothing-like objects) Immersive items (water, sand, noodles, digs) *TOUCHSCREENS OR BRAILLE DO NOT QUALIFY AS A TACTILE ELEMENT Area has some inaccessible or challenging spots for accessibility (steps, narrow, crawl spaces) Interactive Appraisal Post-Production Exhibit: ________________________________________________________ Date: _______________ Interactive: _________________________________________________________________________ Target Audience Age: _____________________________ Evaluator: _______________________________ Credentials/Title: ________________________________ Notes: SELECT ALL THAT APPLY for the interactive piece: *Double-boxed, bold/Italicized elements are highly recommended for showstopper exhibit pieces (10). Auditory Audio has startling features Audio has contrasting sounds in pitch or competing tones of sounds Audio consists of clear voice recording Audio consists of varying accents (compared to proximal geographic region), radio static, or other elements that may alter understanding or clarity Interactive's space has noted sound-bleed competing with the interactive's audio Instructions are provided in a clear, concise manner with good timing in sizable chunks Audio has multiple features, such as voices, nature, and sound effects Not applicable (interactive has no audio; does not seem to need any) Interactive has no audio and might benefit from the addition Visual Interactive space has low or dimmed lighting, follows a subtle color palette, or softer tones of light Movement Fine motor activities (such as drawing with utensils, sculpting, and/or manipulation with the hands) Tactile Touchables that present as supplementative or a new learning opportunity and conveys information Lighting or other visuals have fast movement or flashing elements Gross motor activities that are replicable of a general sport or ordinary movement (balancing, shooting basketball) Educational touchables that can be manipulated with the hands (clay, dolls, etc.) Educational touchable objects that are fixed in position (bronze dino) Videos or spotlights project notable light/glares or shadows into viewing space of interactive Gross motor activities that require more advanced skills or greater participation or force Touchables that are 'loose parts' (toy trains, dolls) and add to the educational experience or free play Few signs, text, or labels within interactive space (not including instructions on screen) Moderate signs, text, and labels that may require additional reading time (in space or on ineractive screens) Ability to operate (buttons, levers, slides) and/or navigate (moderately move objects through/across space) Interactive space has bright lights and/or bright colors Interactive's visual content (space, screens, etc.) is generally easy to scan Interactive's visual content (space, screens, etc.) requires some focus to notice details Interactive's visual content (space, screens, etc.) is heavy on details and require keen attention Instructions are visually provided in a clear manner, adequate sized portions, and good timing Interactive has no visual instructions (does not seem to need any) Interactive has no visual instructions and might benefit from the addition Opportunity to passively ride or moderately change position in (i.e. tiltable chairs) Opportunity to climb over moderately difficult surface, climb up a 5ft + wall, or climb into (over a ledge, etc.) Objects are weighted Raised outlines/tactile edges Temperature-altered (cold or warm) Other Braille present on major labels or signs (titles, start) Braille present on informative texts Other languages are represented (Greek, hieroglyphics, Spanish) Interactive is accessible (ramps, railings, accessible or universal design width/reach) Interactive has some inaccessible or challenging spots for accessibility (steps, narrow, crawl spaces) Audio descriptions are available Wearables (clothing-like objects) Scripts, text, or captioning is consistently readily-available Immersive items (water, sand, noodles, digs) Interactive provides immediate feedback (audio/visual triggered, etc.) *TOUCHSCREENS OR BRAILLE DO NOT QUALIFY AS A TACTILE ELEMENT Interactive has obvious affordance from a visitor's perspective, or their presence suggests that there is an interactive opportunity Interactive provides multisensory content delivery (3+ paired: audio, visual, text, tactile, and/or movement) Main message for learning/exhibit are inferred or obvious Week 1 (1/111/16) DCE Stage (orientation, screening/evaluation, implementation, discontinuation, dissemination) Orientation Weekly Goal 1) Complete physical orientation by end of week 1 2) Assigned 2-3 exhibits for recommendations, sensory development, and understanding exhibit lifetime/design Objectives Tasks Meet with Intern Manager, Site Mentor (accessibility coordinator), and Director of Research & Evaluation to introduce and collaborate on project and experience for the 14-week placement. Security and orientation walk-through; virtual new staff orientation Develop usability and understanding of sensory-enriched environment assessment tool (SEEAT) plans with mentor(s). 2 (1/171/23) Orientation; screening/evaluation 1) Collaborate on SEEAT outline & expectations 2) Review literature & expand search on sensory and Observe 3 exhibits as a model for sensory & accessibility recommendations where lacking or noted problem areas for tool development Date complete 1/15/22 Gallery walk-through with mentor(s) on 3 exhibits Receive resources to begin orienting to 3 exhibits, research, and exhibit design Complete orientation paperwork, badging; determine need for Teams & TCM email accounts Determine weekly meeting times with mentor(s) Begin formatting options and feedback meeting with mentor(s) for tool development Finalize MOU & IRB expectations 1/21/22 accessibility features 3) Join exhibit Teams and meetings Gather and review research articles for sensory stimulation Develop content for tool Review museum resources for goals, project development, research & evaluation process Begin sitting-in on team meetings and introducing to staff 3 (1/241/30) Screening/evaluation 1) Revisit tool expectations 2) Advocate for tool to exhibit development teams 3) Receive feedback on soft 1st draft of tool for content & structure Revise MOU timeline & IRB considerations Become efficient at describing the expectations and need for tool to team members Utilize resources provided for tool design Meet with faculty mentor to discuss project progress Meet with faculty mentor & review all project updates, gain feedback & share considerations Establish a direction with tool content, direction, scoring, and use/manual Present tool purpose and status with teams as indicated 1/28/22 4 (1/312/6) 5 (2/72/13) Screening/evaluation Implementation 6 (2/142/20) Screening/evaluation; Implementation 7 (2/212/27) Screening/evaluation 1) Revise tool based on feedback and research 2) Develop 1st hard draft of SEEAT Design tool for userfriendly environment evaluation Revisit research and perform continued literature search to bolster tool and its elements Receive mentors feedback on tool, scoring, manual, and utility st 1) Utilize 1 draft tool Visit museum to to evaluate an perform soft trial established exhibit evaluation on one newer/established 2) Use tool outcomes exhibit to provide recommendations Meet with Yvonne in UIndy IRB to 3) Establish IRB determine project status status 1) Discuss SEEAT Revise tool as with TCM grant indicated advisors Discuss goals and 2) Revise plan and objectives of project tool(s) with with mentors mentors 1) Revise SEAT Revisit literature for nd materials for 2 qualitative objectives draft Set-up a date & exhibit to trial evaluate 2/4/22 Discuss tool during weekly site mentor meeting Revise tool as indicated Schedule days onsite for exhibit evaluations 2/8/22 Research museum objectives for designated exhibits & brainstorm recommendations Build foundations for additional tools (museumspecific qualitative documents; one during schematic phase and one for postproduction/remedial) Schedule meeting with exhibit designers/developers to 2/18/22 2/23/22 Revise SEAT materials 8 (2/283/6) 9 (3/73/13) Screening/evaluation; Implementation Implementation 2) Outline for qualitative documents (ASI appraisals) 1) Begin development Discuss qualitative of ASI appraisals project with exhibit developers/designers 2) Finish 2nd draft of all SEAT materials Revise SEAT manual for 2nd draft 1) Trial and revise SEAT 2) Preliminary ASI appraisals 10 (3/143/20) Screening/evaluation; Implementation 1) Start M-SEAT drafts 2) ASI appraisal 1 drafts Reconsider SEAT vs museum-specific version (M-SEAT) Formatting of first draft ASI appraisals Develop outlines for M-SEAT and appraisals st create qualitative documents Request feedback for 2nd draft SEAT forms Schedule onsite days for SEAT use to evaluate problematic and new exhibits 3/7/22 Start formatting qualitative documents Trial SEAT in problematic exhibit to assess tool capturing sensory features Discuss conceptual formatting and design of appraisals Discuss SEAT trials Outline for M-SEAT version Exhibit ASI appraisal outline Interactive ASI Appraisal outline 3/11/22 3/22/22 11 (3/213/27) Implementation 1) Trial 1st drafts of M-SEAT and ASI Appraisals Trial each tool/form and prepare tools for training/use by other users 2) Reformat manuals for each tool Identify exhibit and interactives to assess via tools 3/25/22 Identify user populations for manuals Complete trials and data analysis 12 (3/284/3) 13 (4/44/10) 14 (4/114/17) Implementation Implementation; Discontinuation Discontinuation; Dissemination 1) Revise M-SEAT materials for 2nd draft 2) Revise ASI Appraisals for 2nd draft 1) 2nd trials of MSEAT and ASI Appraisals 1) Revisions for 3rd drafts 2) Trials with 3rd drafts 3) Dissemination planning for site Collaborative revisions to improve efficiency and clarity of tools Discussion meeting with all evaluators for revision brainstorm 3/31/22 Draft 2nd drafts Trial all tools again to comparatively analyze among evaluators and between 1st and 2nd trials progress Improved connectivity and limited further revisions Quick turn-around for 3rd trials that would assess every sensory section, challenging Revisit literature Schedule trials for collaborative appraisal trials Create timeline for MSEAT trial, data analysis, and 3rd drafts/trials Dissemination planning for research & evaluation working group; accessibility & inclusion working group Final drafts timeline Revise for 3rd drafts 4/7/22 4/19/22 Identify exhibit for final trials 15 (4/184/24) Discontinuation; Dissemination 1) Disseminate DCE 2) Finalize drafts for tool materials 3) Provide site mentors with final drafts for future use Present to each working group Timeline for revisions on final drafts Finalize end of DCE Shared Google Drive with site mentor for all resources Encourage TCM staff to collaborate with mentors for access and training/use Doctoral Capstone Experience and Project Weekly Planning Guide 4/24/22  ...

... SHARED DECISION MAKING TRAINING EVALUATION 1 Shared Decision Making (SDM) Training Program Evaluation for Occupational Therapy Students and Practitioners Morgan E. Herrmann, Zoelaine T. Viewegh, Livia M. Crispen, Kayleigh H. Smith, Angela L. Kilbride, Shelby E. Hudson December 16, 2022 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: Dr. Penelope A. Moyers, Ed.D., OT, FAOTA is retired from the University of Indianapolis Author Note Penelope A. Moyers https://orcid.org/0000-0002-4043-4108 Acknowledgement: Researchers would like to thank Taylor A. Gurley, OTR, MS, OTD for her role with facilitating SDM application in the MOT Wellness in Occupation course. Correspondence concerning this article should be addressed to Penelope A. Moyers, School of Occupational Therapy, University of Indianapolis, 1400 E. Hanna Avenue, Indianapolis, IN 46227. Email: moyers@uindy.edu SHARED DECISION MAKING TRAINING EVALUATION 2 A Research Project Entitled Shared Decision Making (SDM) Training Program Evaluation for Occupational Therapy Students and Practitioners 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: Morgan E. Herrmann, Zoelaine T. Viewegh, Livia M. Crispen, Kayleigh H. Smith, Angela L. Kilbride, Shelby E. Hudson Doctor of Occupational Therapy Students Approved by: Research Advisor 12/20/2022 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 SHARED DECISION MAKING TRAINING EVALUATION 3 Abstract Objectives Shared decision making (SDM), an approach for client-centered care, gives clients a role in their health management. The purpose was to assess a SDM training programs effectiveness for master of occupational therapy (MOT) and social work (MSW) students, and participants at the 2021 Indiana Occupational Therapy Association (IOTA) fall conference. Study Design Mixed methods program evaluation. Methods Training and evaluation methodology included the six disciplines of learning (Pollock et al., 2015) when implementing the SDM training program, and the four levels of evaluation of Kirkpatrick and Kirkpatrick (2016) to promote and evaluate the transfer of learning post-training. A variety of surveys for each evaluation level formed the basis for criteria to determine effectiveness for each outcome and for the overall program. Results Knowledge scores improved from pretest to posttest for all participants [ t (28) = 5.957, p = .001], as well as improved for attitude scores [F(1, 22) = 24.51, p < .001]. Study participants exhibited a strong confidence in applying SDM knowledge in their settings, M = 8.24, SD = 1.261, 95% CI [7.66-8.81], and a high level of commitment to applying SDM in future practice M = 8.33, SD = 2.153, 95% CI [7.35-9.31]. We met the required criteria for program effectiveness. Conclusions The SDM training program is a facilitator of client-centered practice giving clients an active role in their care. Knowledge and attitudes of students and practitioners towards SDM improvement highlights the need for SDM training in educational and clinical setting. SHARED DECISION MAKING TRAINING EVALUATION 4 Shared Decision Making (SDM) Training Program Evaluation for Occupational Therapy Students and Practitioners Shared decision making (SDM) is an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options to achieve informed preferences (Elwyn et al., 2012, p. 1361). Shared decision making is a strategy for providing client-centered care in a manner that encourages and gives clients a role in the management of their health (Smith, 2016). Health professionals can provide client-centered care without implementing SDM strategies; however, the description of client-centered care is broad and lacks specific methods for the provider and client to work together (Smith, 2016). According to Hughes et al. (2018), there is an association between a lack of SDM use and poor client-reported health outcomes, and higher healthcare utilization. It is rare to find shared decision making in most health professions curricula or continuing education programs, which creates a serious problem given that a lack of practitioner skills in SDM has the potential to lead to poor client outcomes (Hughes et al., 2018). It is essential that future health professionals receive education about the SDM process. Because of a lack of training, health care practitioners typically do not practice SDM when treating clients; however, they may be using other strategies for client-centered care, such as collaborative goal setting (Baker et al., 2001). Problem Statement Shared decision making training for healthcare students would be beneficial given that clinicians are not incorporating SDM into their practice (Volk et al., 2014). Shared decision making is not in the curricula of many entry-level or post-graduate level healthcare programs (Hoffmann et al., 2014). This means that many health professionals are entering the field without SHARED DECISION MAKING TRAINING EVALUATION 5 an understanding of SDM and the skills related to its effective use. Many educational institution leaders have not been eager to implement SDM into their curricula because of a lengthy accreditation process to gain approval for major curriculum changes (Yap et al., 2019). Many organizational leaders are aware of SDM concepts, but there is minimal evidence of SDM implementation in clinical practice (Stiggelbout et al., 2015). According to our systematized literature review (Moyers et al., 2020), minimal research about SDM training within health profession programs exists. However, the research completed on SDM training provided some evidence that training was effective in providing health care students more knowledge about the decision making process (Durand et al., 2018). Despite increasing the students knowledge, the training did not always foster the successful implementation of SDM in practice (Durand et al., 2018). Barriers to the successful implementation of SDM include time limitations, insufficient knowledge about SDM, and negative attitudes from clinicians toward SDM (Durand et al., 2018). Indication from research shows that there is also a lack of guidance for practitioners to follow regarding the implementation of SDM in practice (Elwyn et al., 2012). In addition, few SDM training programs are available for healthcare students, with one study finding only eleven SDM courses embedded in undergraduate medical curricula across six countries (Durand et al., 2018). Thus, it is evident that there is a need for SDM training not only to increase knowledge about SDM, but also to facilitate the application and implementation of SDM in practice. Including SDM training within health professional curricula is important for the future of SDM in healthcare. Previous researchers found that SDM training for health profession students improves skills, knowledge, and confidence; however, there is currently little research about the transfer of training from course work to practice (Durand et al., 2018; Hoffmann et al., 2014). SHARED DECISION MAKING TRAINING EVALUATION 6 Purpose Statement The purpose of this program evaluation was to implement and assess the effectiveness of a client SDM training program for entry-level master of occupational therapy (MOT) and master of social work students (MSW) from the University of Indianapolis. The first aim of the study was to modify existing SDM training programs found in the literature (Durand et al., 2018) to align with the six disciplines of learning (Pollock et al., 2015). The second aim of the study was to evaluate the effectiveness of the training through the four levels of evaluation of Kirkpatrick and Kirkpatrick (2016), which is a program evaluation method that determines the transferability of training to real-world application. The third aim of this study was to evaluate the training, pre and post, with a sample of participants at the virtual Indiana Occupational Therapy Association fall conference in 2021. Theories We used Elwyns Shared Decision Making Model (Elwyn et al., 2012) to guide the development of the SDM training for healthcare professionals. According to this model, a clinician should encourage the client to actively take part in making clinical decisions using three main components. Choice talk, the first step of the SDM model, ensures the client understands all available intervention options. Next, option talk helps the client examine all the options available to the client. Decision talk is the final step of the SDM model referring to the process that the healthcare professional and the client experience while trying to identify the clients best option (Elwyn et al., 2012). We also used the six disciplines of training approach (Pollock et al., 2015) to guide the development of the SDM training, which is further described in the literature review. These disciplines of training provide a thorough approach to designing an effective training program SHARED DECISION MAKING TRAINING EVALUATION 7 with accompanying checklists to follow throughout the development of the training (Pollock et al., 2015). These disciplines aid in defining program outcomes, designing a training program that fosters a transfer of learning, and documenting the results to improve the training program for the future (Pollock et al., 2015). To evaluate the effectiveness of the SDM training, we used the Kirkpatrick Evaluation Model (Kirkpatrick & Kirkpatrick, 2016). This approach involves four levels of evaluation for training programs including criteria for assessing reaction, learning, behavior, and results. The level one evaluation, known as the reaction evaluation, evaluated the extent to which the participants found the training engaging, beneficial, and relevant (Kirkpatrick & Kirkpatrick, 2016). The level two evaluation, known as the learning evaluation, measured how well the participants obtained the knowledge, skills, and attitudes about SDM based on their participation in the training (Kirkpatrick & Kirkpatrick, 2016). The level three evaluation, known as the behavior evaluation, guided us in the analysis of the actual behavior change and whether the participants applied what they learned during the training while they were working with clients as part of one of their graduate courses (Kirkpatrick & Kirkpatrick, 2016). The level four evaluation, known as the results evaluation, evaluated whether the participants achieved the original outcomes developed for the training (Kirkpatrick & Kirkpatrick, 2016). Adaptation of the Kirkpatrick Evaluation Model to the setting or context of the training is possible. Feedback from participants is a key component of this model as it provided us with direct input about the skills and attitudes of those who completed the training (Masood & Usmani, 2015). Significance Shared decision making helps clients become more engaged in their intervention plan so that the plan addresses the needs and desires of each individual client (Smith, 2016). When SHARED DECISION MAKING TRAINING EVALUATION 8 practitioners engage clients in SDM for the planning and execution of their intervention plan, clients are more likely to engage in therapy overall, which can lead to better intervention outcomes (Pollock et al., 2015). Researchers have found a connection between SDM training and increased positive attitudes of providers toward using SDM in practice (Ospina et al., 2020); however, healthcare providers have not integrated SDM within their practices. This lack of integration is possibly due to a need for more training (Volk et al., 2014). Previous researchers determined that the most effective training curricula led to an increase in positive attitudes, beliefs, skills and knowledge about SDM (Hoffmann et al., 2014 & Butow et al., 2014). The findings of our research study contributed to the understanding of SDM training effectiveness and transferability. Literature Review General Information on SDM & Past Training Programs Previous researchers studied the effectiveness of SDM training programs on participant knowledge, skills, and attitudes (Hoffmann et al., 2014 & Butow et al., 2014). Hoffmann et al. completed a randomized controlled trial to determine the effectiveness of a brief SDM training intervention on participant knowledge and attitudes towards SDM (2014). The intervention group met for a single one hour session including a presentation, video demonstration, and a collaborative discussion on strategies for SDM implementation (Hoffmann et al., 2014). There were 107 total participants divided into intervention and control groups respectively. The same intervention session was repeated multiple times, limiting each session to only eighteen participants (Hoffmann et al., 2014). The researchers found an increase in participant knowledge on SDM and increased confidence towards SDM implementation (Hoffmann et al., 2014). Similarly, Butow et al. (2014) completed a single seven-hour face-to-face SDM intervention that SHARED DECISION MAKING TRAINING EVALUATION 9 included written and oral materials, role play videos and practice, and guided discussion to critically analyze the SDM process. They found a significant increase in collaborative communication amongst their participants but noted a more intensive follow-up would be beneficial to increase the transfer of knowledge (Butow et al., 2014). Both of these studies involved currently employed healthcare professionals, thus representing a need for additional research on training for pre-professional healthcare students. Despite efforts to design and implement SDM training protocols, there is a continued lack of implementation of SDM in both client care and higher education curriculum. Only one quarter of medical student responses to one study indicated SDM was in their curriculum (Meats et al., 2009). This lack of curricular emphasis occurs even though other educational research on SDM found improvements in SDM skills, attitudes, and comfort levels of both health profession students and clinicians when interacting with clients (Ospina et al., 2020). This support of SDM formal education is indicative of a need to close the research gap for both students and healthcare professionals in their implementation of SDM within healthcare. The Six Disciplines of Breakthrough Learning An effective training program is a program that is designed according to a training methodology to incorporate specific principles. To ensure the transfer of learning was most effective, we constructed the SDM training program using the six disciplines of breakthrough learning (Pollock et al., 2015). The six disciplines are training strategies that include: defining organizational outcomes, designing the complete experience, delivering for application, driving learning transfer, deploying performance support, and documenting results (Pollock et al., 2015). Each discipline has a series of checklists for the users convenience that outline the most crucial steps for completing the requirements of the training discipline (Pollock et al., 2015). SHARED DECISION MAKING TRAINING EVALUATION 10 The first of the six disciplines is defining the training outcomes. Within the first discipline, two checklist items (Pollock et al., 2015) prompt exploration of non-training solutions and environmental factors that could impact the implementation process. The last three checklist items help to further refine the training objectives. Overall, this first discipline provides a guide to establish clear, reasonable, and measurable objectives to address student and practitioner gaps in knowledge, skills, and attitudes about SDM (Pollock et al., 2015). The second and third disciplines guide the development and implementation of the training program (Pollock et al., 2015). The second discipline entails designing the complete learning experience from any pre-training, training, and follow-up expectations. There should be congruence between the desired outcomes of the training, the planned learning activities, and follow-through transfer and application. This discipline allowed us to view the training participants' learning as a continuum that develops before the instruction portion of the training and continues developing afterward (Pollock et al., 2015). The third discipline guides the planning of delivery for application including narrowing the gap between the learning and the actual doing in practice as a way of accelerating transfer, creating a desire to learn, making relevance to participants clear, and providing concise instructions and actions (Pollock et al., 2015). This discipline assists in the analysis of how the participants learn best and the modes of instruction that are most effective for the delivery of the application. Checklist items under this discipline include: incorporating relevant examples, stories, or simulations to help facilitate learning of the content; including job-aids in the instruction and practice exercises; constructing the training materials to closely align to the participants actual transfer environment; and making the preparatory work essential to the participants success in the training (Pollock et al., 2015). SHARED DECISION MAKING TRAINING EVALUATION 11 The use of the fourth discipline, drives learning transfer, and encourages training developers to actively manage and follow through with the learning process (Pollock et al., 2015). A few of the checklist items under this discipline include participants and managers meeting or communicating following the training, putting processes in place to remind the participants to apply their learning, and providing recognition to participants who make remarkable progress (Pollock et al., 2015). Use of the fifth discipline, deploy performance support, ensures the inclusion of aspects in the training program that would increase the participants confidence in their knowledge and abilities about SDM (Pollock et al., 2015). The goal of this discipline is to increase the probability that the participants will successfully implement their new skills in their professional setting. Lastly, the sixth discipline involves documentation of the results. According to this discipline, results must be relevant to the outcomes of the program, credible, compelling, and efficient (Pollock et al., 2015). The checklist items under this discipline guide the selection of the best evaluation methods, identifying appropriate data collection strategies, and using easily interpreted data analysis to discern improvement (Pollock et al., 2015). Kirkpatrick Blended Evaluation In addition to the six disciplines of learning (Pollock et al., 2015), we used Kirkpatricks (Kirkpatrick & Kirkpatrick, 2016) approach for evaluating training and educational programs through four levels of training evaluations. The four levels of evaluation in this approach include reaction, learning, behavior, and result. This approach to program evaluation allows for creating, refining, and contextualizing the evaluation and assessment processes to determine whether the outcomes are met within the training program (Kirkpatrick & Kirkpatrick, 2016). SHARED DECISION MAKING TRAINING EVALUATION 12 The first level is the reaction evaluation, which is how the participants react to the training experience and their thoughts about moving forward with the transfer of training. This reaction evaluation entails having the training participants provide feedback on the contents of the training, materials, instructors performance, delivery method, and learning environment. Kirkpatrick provides templates for all of the evaluations and gives general permission to customize these templates as needed to meet program evaluation needs and to ensure questions are credible and useful (Kirkpatrick & Kirkpatrick, 2016). The Blended evaluation approach evaluates multiple Kirkpatrick levels at a time (Kirkpatrick & Kirkpatrick, 2016). This tool for level one can expand to include questions appropriate for a level two evaluation as well as questions about confidence and commitment to apply knowledge learned (Kirkpatrick & Kirkpatrick, 2016). The items are learner-centered and customized to fit the needs of the program evaluation (Kirkpatrick & Kirkpatrick, 2016). The second level of evaluation is the learning evaluation, which determines if there is a change in attitude, improved skills, and an increase in knowledge about the training topic (Kirkpatrick & Kirkpatrick, 2016). This level illustrates the merit of the program and how it trains the participants in different contexts. According to this level, the evaluation of learning should occur through pre-learning and post-learning assessments to determine the participants accuracy and comprehension after the training program (Kirkpatrick & Kirkpatrick, 2016). In addition, there should be a clear scoring process in the evaluation method (Kirkpatrick & Kirkpatrick, 2016). The third level is the behavior evaluation. This is one of the most crucial steps in the process as the evaluation methods assess whether the participants are applying what they learned in the training during their real-life experiences (Kirkpatrick & Kirkpatrick, 2016). Lastly, the SHARED DECISION MAKING TRAINING EVALUATION 13 fourth level is the result evaluation. This level determines how well the achieved outcomes of the training program fit with the believed outcomes (Kirkpatrick & Kirkpatrick, 2016). It is important to align the level four evaluation method directly with the outcomes for which the training is targeted to achieve. Methods The researchers obtained Institutional Review Board (IRB) approval from the University of Indianapolis where the study took place and obtained informed consent from all participants under the approved IRB proposal. Participants Researchers formed a sample through students in an interprofessional evidence-based practice course, where a total of 11 MOT and four MSW students were enrolled in the course. Of the 11 students in the course, eight students, all from the MOT program, consented to participate in our study. There were originally nine participants who volunteered for the study, including one student in the MSW program. The social work student participant dropped from the study prior to completion of post-training surveys and the application to practice portion of the study. The MOT and MSW student study participants attended their dedicated course lab time for the SDM training that we developed and led. An additional 20 study participants who signed consent were attendees at the Indiana Occupational Therapy Association (IOTA) fall conference in 2021. These attendees registered for and attended our session Patient Shared Decision Making Training for Occupational Therapy Practitioners. Design We used a descriptive program evaluation that involved cross-sectional surveys timed to follow Kirkpatricks approach for evaluating training programs through the four levels of SHARED DECISION MAKING TRAINING EVALUATION 14 training evaluations (Kirkpatrick & Kirkpatrick, 2016). The six disciplines of breakthrough learning (Pollock et al., 2015) guided the development of the training. The main program evaluation question for this study was: What is the effectiveness of the shared decision making training program in transferring learning from the occupational therapy entry-level didactic educational classroom experience to an application classroom setting involving client volunteers? In addition to the main program evaluation question, we addressed the following sub-questions: 1. What is the difference in SDM knowledge pre- and post-training for the MOT/MSW students and the IOTA participants (Forcino et al., 2018)? 2. What is the difference in SDM attitude pre- and post-training for the MOT/MSW students and the IOTA participants (Forcino et al., 2018)? 3. What is the difference in knowledge and attitudes toward SDM between the MOT/MSW students and the IOTA participants (Forcino et al., 2018)? 4. What is the difference in the evaluation of the SDM training on the Blended evaluation (Kirkpatrick & Kirkpatrick, 2016) between the MOT student group and the IOTA participant group? 5. What are the results of the MOT students on the modified SDM survey (Hrter & Scholl, 2018; Moyers et al. 2021)? 6. What are the results of the MOT students on the Delayed Post-Training Survey (Kirkpatrick and Kirkpatrick, 2016)? 7. What are the results of the MOT students on the OPTION Scale (Elwyn et al., 2013)? SHARED DECISION MAKING TRAINING EVALUATION 15 Intervention Training The MOT and MSW students engaged in the SDM training during one class period of their interprofessional evidence-based practice course. We also conducted the training with the IOTA attendees registered for our training session during the 2021 fall conference. As previously stated, the six disciplines of breakthrough learning (Pollock et al., 2015) guided the construction of the SDM training program to address the transfer of learning to client application. We used the first of the six disciplines to thoughtfully develop training outcomes that were likely to change practice to include the SDM process. We followed the first discipline checklist (Pollock et al., 2015) to fully develop the training idea and to determine whether there was a need for its implementation within the College of Health Sciences at the University of Indianapolis and at the IOTA fall conference. After determining the need for training implementation, we developed the following objectives for the training that clearly defined criteria for a successful program according to the first discipline (Pollock et al., 2015). The following objectives for the SDM training emerged. The participants in the training will: 1. Demonstrate knowledge of shared decision making. 2. Describe attitudes supportive of shared decision making. 3. Demonstrate the ability to implement shared decision making into session activities. 4. Apply, as an MOT student, the shared decision making knowledge and skills in a classroom setting with a client volunteer. Following the checklist items within the second discipline (Pollock et al., 2015) allowed us to create meaningful preparatory work for the SDM training to maximize the application of SHARED DECISION MAKING TRAINING EVALUATION 16 learning. For the MOT and MSW student participants, the program design included a preprogram meeting, the training experience, a post-training application of learning, and posttraining evaluations. Following the checklist within the second discipline (Pollock et al., 2015) ensured the prioritization of all phases of training while specifically connecting each phase of the learning to the ultimate goal for the MOT and MSW participants to transfer their learning from the training to the application with clients. We followed the checklist items under the third discipline (Pollock et al., 2015) throughout the development of the training for both the MOT and MSW students and the IOTA participants. The components selected for the training were thus relevant and applicable to all participants, while promoting transfer of learning. The training began with a short introductory video informing the participants about SDM (Osmosis, 2018). We then included information about the core components of SDM, steps to follow, and tools for implementation. These tools included an SDM pocketcard (Braddock et al., 2008), the OPTION scale (Elwyn et al., 2013), the Ottawa Personal Decision Guide (OConnor et al., 2015), and the A to Z Inventory of Patient Decision Aids (The Ottawa Hospital Research Institute, n.d.). A comprehensive list of the tools used during our training can be found in Table 1. At the end of the didactic training, we demonstrated SDM so the participants were able to see the potential for use of SDM in practice. We engaged with the participants in discussion after the demonstration to promote critical reflection. The training delivered to the MOT and MSW students also included a role-play activity for the participants. Through role play, we offered an opportunity for the participants to practice what they learned when using sample case scenarios. Participants were able to engage in SDM with input from researchers to ensure learning and proper application of SDM occurred, which was a critical aspect for the transfer of knowledge SHARED DECISION MAKING TRAINING EVALUATION 17 from the training session to application of SDM with the Community Patient Resource Group (CPRG) clients. The CPRG client volunteers were members of the community with varying diagnoses who volunteered their time to give students experience in working with clients. The IOTA participants did not receive this role-play activity due to limitations associated with the online conference format. In place of the role play activity, we demonstrated SDM using the Ottawa Personal Decision Guide (OConnor et al., 2015). This SDM demonstration differed from the student presentation as we included a completed version of the Ottawa Personal Decision Guide (OConnor et al., 2015). After reflecting on our initial presentation with the MOT and MSW students, we found that it lacked thorough instruction on the use of the provided SDM tools with evidence-based intervention recommendations. Consequently, we created a sample Ottawa Personal Decision Guide (OConnor et al., 2015) for a client with a central field deficit and used the Occupational Therapy Practice Guidelines for Older Adults With Low Vision to guide our intervention selection (Kaldenberg & Smallfield, 2020). This SDM demonstration not only educated the IOTA participants on how to use the provided SDM tool, but also emphasized the importance of providing evidence-based interventions to their clients. The fourth discipline (Pollock et al., 2015) guided engagement with the student participants after the training ended and promoted maximal transfer of learning from their didactic classroom experience. To further the student participants success, we provided twelve reminders via email communication with consenting participants about their classroom experience using SDM. The checklist items within the fifth discipline guided us in the creation of an appropriate transfer climate that led to optimal success for the participants (Pollock et al., 2015). Offering practice application aids and SDM materials during both training sessions was the first step to SHARED DECISION MAKING TRAINING EVALUATION 18 creating the optimal transfer climate. Materials provided to participants included the SDM training learning objectives, Elwyns Three Step Model for SDM, patient consent form, OPTION Scale (Elwyn et al., 2013), Ottawa decision aid tool (OConnor et al., 2015), the A to Z Inventory of Patient Decision Aids (The Ottawa Hospital Research Institute, n.d.), and student SDM assignment handout. The student participants also received additional SDM materials via email following the training to better facilitate their transfer of learning to their classroom client experience. According to the sixth discipline (Pollock et al., 2015), the last part of training development involves selecting the appropriate evaluation and data collection methods for accurate documentation of results of the program evaluation. The chosen evaluation and data collection methods should clearly indicate whether the training program helped improve participant performance. To ensure we followed this discipline, we designed an extensive evaluation process to gather relevant data. Information regarding our evaluation methods can be found in the instruments section of this paper, or in Table 2. Table 3 lists the program effectiveness outcomes matched to the measures for each level of the Kirkpatrick evaluation (Kirkpatrick & Kirkpatrick, 2016). We developed these program evaluation effectiveness outcomes using the methods of Guild (1990) and Fink (2005). Pilot Procedures In the Fall of 2021, we piloted the SDM application procedures to ensure the MOT students effectively applied SDM when working with clients. As a research team, we paired ourselves into groups of two to work with one CPRG client. The pairs conducted initial evaluation sessions and subsequent intervention sessions to meet the clients needs. Following the intervention session, each pair of researchers used the OPTION scale (Elwyn et al., 2013) to SHARED DECISION MAKING TRAINING EVALUATION 19 collaboratively evaluate and score ourselves on our use of SDM throughout the intervention session. We found one problem with the intervention procedures through this pilot involving client attendance at both sessions. If the client missed one of their sessions, this problem of attendance compromised the students ability to complete the SDM process using the OPTION scale (Elwyn et al., 2013) during the intervention session. To avoid this attendance problem, we altered the schedule to allow additional time for the student participants to complete the SDM intervention procedures in case a client needed to reschedule. Post Training of the MOT Participants Consenting participants in the MOT program received post-training assignments including implementation of SDM with a Community Patient Resource Group (CPRG) client following the training that occurred Fall semester 2021. These assignments took place during the Spring semester 2022 in their MOT 505: Wellness in Occupation course. The MOT Student participants rated each other following SDM implementation with the Option Scale (Elwyn et al., 2003). Additionally, the MOT students completed a survey about their personal demonstration of SDM with the CPRG client volunteers (Hrter & Scholl, 2018; Moyers et al. 2021) and one final survey about their SDM knowledge and progress related to program outcomes (Kirkpatrick & Kirkpatrick, 2016). Instruments Baseline Measurement We used the four levels of evaluation from Kirkpatrick and Kirkpatrick (2016) to guide data collection regarding the effectiveness of the training (see Table 2). We administered a pretest using the SDM Knowledge and Attitudes Survey (Forcino et al., 2018) at the beginning SHARED DECISION MAKING TRAINING EVALUATION 20 of the training. This survey included two sections, the first part including 10 true/false statements that assessed the students knowledge of SDM. The second part of the survey contained 10 attitudinal items with a four-option Likert response scale, with one indicating strongly disagree, and four indicating strongly agree (Forcino et al., 2018). We reverse scored questions 11 and 17 on the attitude portion of the survey due to the more favorable response being strongly disagree. In terms of construct validity, the authors used a literature review to detail important SDM processes and outcomes to guide the development of the survey items (Forcino et al., 2018). There is no reliability established for this instrument. The authors of this instrument stated that the true/false design of the knowledge portion of the survey without an I dont know option may lead to error due to the inability to distinguish between those who do not know the material and those who have a misunderstanding of the material (Forcino et al., 2018). We received permission to use and modify this survey, and added an I dont know option to each statement to address this error in interpretation and to improve reliability and validity. We totaled the I dont know responses for the MOT/MSW and IOTA pre-knowledge as well as post-knowledge to determine if there was a change in the I dont know scores. Scores of the knowledge portion were the number of items correct, and the participants received a percentage of correct responses out of the items completed with a true/false response. The attitudes portion of the survey created a raw score through totaling the scores on each item. Level 1-Reaction Evaluation We used a level one evaluation (see Table 2), known as the reaction evaluation (Kirkpatrick & Kirkpatrick, 2016). We used the Participant Survey items of the Kirkpatrick Blended evaluation approach (Kirkpatrick & Kirkpatrick, 2016) at the completion of the training for the level one evaluation method because of the applicability to our training design; SHARED DECISION MAKING TRAINING EVALUATION 21 however, there is no established reliability or validity for this tool. This survey consisted of both Likert scale and open-ended questions for a total of 13 items. The first Likert scale was an agreement scale that applied to seven items, 0 meaning the participant strongly disagrees with the statement and 10 meaning they strongly agree with the statement. Following this Likert scale were two open-ended questions about what they will be able to apply when working with future clients and any resources or assistance they would need to apply what they learned. Following these open-ended questions were two more Likert scale questions to determine the perceived level of confidence. A score of 0 indicated not at all confident and a score of 10 indicated extremely confident. Lastly, there were two more open-ended questions to complete the survey about what outcomes they hope to achieve as a result of their efforts and any additional feedback. Level 2-Learning Evaluation We then used a level two evaluation (see Table 2), referred to as the learning evaluation, which served as a post-training assessment (Kirkpatrick & Kirkpatrick, 2016). We gathered this data through the SDM Knowledge and Attitudes Survey (Forcino, et al., 2018) as described previously. Level 3-Behavior Evaluation Next, we used a level three evaluation (see Table 2), referred to as the behavior evaluation, to gain feedback on the application or effectiveness of the training. We gathered this information with the Kirkpatrick and Kirkpatrick (2016) Delayed Post-Training Survey and the OPTION scale (Elwyn et al., 2003). There is no reliability or validity established for the Delayed Post-Training Survey (Kirkpatrick & Kirkpatrick, 2016). The Delayed Post-Training Survey (Kirkpatrick & Kirkpatrick, 2016) consisted of ten questions that were either open-ended or used SHARED DECISION MAKING TRAINING EVALUATION 22 a Likert scale. The Likert scale was an agreement scale asking the participants to rank each question from one indicating they strongly disagree with the statement, to four indicating they strongly agree with the statement. There was also an option to select N/A, not applicable. The first two questions were about the training itself. Questions three, four, and five were about the practical application of SDM to the client. Question three used a Likert scale about whether they thought they were successfully applying what they learned in the training, and questions four and five asked the participant to check all of the reasons that applied based on their answer to question three. Questions six, seven, and eight were about the SDM training overall using a Likert scale. Questions nine and ten requested feedback about what went well and asked for suggestions for the future in an open-ended format. Each section with Likert scale questions had options to add typed comments to provide any further explanations. We then used the OPTION scale (Elwyn et al., 2013) to measure the extent to which the student participants involved their clients in the decision making process of their intervention sessions. The OPTION scale had descriptions of five items that participants should observe in the shared decision making process (Elwyn et al., 2013). Each item contained a statement, along with a score from 0 to 4 detailing the extent to which the individual engaged in that aspect of SDM (Elwyn et al., 2013). Zero indicated there was no effort, and 4 indicated there was an exemplary effort (Elwyn et al., 2013). The original OPTION scale consisted of 12 items, and the tool developers used a development process based on qualitative studies with a high quality level (Elwyn et al., 2003) to establish its construct validity. Additionally, they pilot-tested the tool with groups of clients and clinicians, which led to further refinement of the original tool (Elwyn et al., 2003). Despite these efforts to develop a strong client-reported measure of shared decision making, data from SHARED DECISION MAKING TRAINING EVALUATION 23 previous studies of the OPTION 12-item scale showed that practitioners were not achieving high levels of shared decision making scores (Elwyn et al., 2013). Elwyn et al. (2013) revisited the 12-item OPTION tool and developed the new five-item version to improve the tools construct validity (Elwyn et al., 2013). They also anticipated improved reliability because the raters have fewer items to assess that are clearly defined and observable (Elwyn et al., 2013). To score the revised OPTION scale, we added each of the five items together, with item scores ranging from 0 to 4 (Elwyn et al., 2013), for a potential total raw score of 0 up to 20 (Elwyn et al.). Rescaling of the raw score occurred on a finalized scale of 0 to 100. Level 4-Results Evaluation Lastly, we used a level four evaluation (see Table 2), known as the results evaluation, to understand how well the participants believed they performed skills from the training during the session with their client. We gathered data through four items from the original Modified SDM Survey (Hrter & Scholl, 2018; Moyers et al., 2021). Following their demonstration of SDM with a client, the participants completed our version of the Modified SDM Survey (Hrter & Scholl, 2018; Moyers et al. 2021) to reflect on their experience and perceived performance. The first item was a single Likert scale question that asked the participant about their knowledge of SDM on a scale of zero to ten. The second item, derived from the Control Preference Scale (Degner et al., 1997), was a multiple choice question with five possible choices about who they believe should make the treatment decision. The third item of this survey was the SDM-Q-9 (Kriston et al., 2009), which contained two open-ended questions where the participants briefly explained their clients health complaint, problem, or illness and the decision made with the client. Nine Likert scale agreement questions followed, referring to the session previously described with choices that range from completely disagree to completely agree. The fourth item SHARED DECISION MAKING TRAINING EVALUATION 24 of this survey addressed barriers to the implementation of SDM. This section contained eight questions with Likert scale choices that ranged from completely disagree to completely agree. There were two barrier questions that were removed from the tool and were not analyzed due to the barriers not being relevant to the study participants. Question 15, the instruction given by the physician (prescription) limit or limited my scope of action and hindered me to actively involve clients in decision making, and question 16, frequent therapeutic transition hinders or hindered me to actively involve clients in decision making were removed. The students did not receive referrals from physicians to work with the CPRG clients and students worked with the participants within two separate sessions, eliminating therapeutic transitions. In addition, the participant had the opportunity to describe their own barrier(s) not listed previously in the eight questions. The SDM-Q-9 (Kriston et al., 2009) has high internal consistency ( = 0.938). All items showed an acceptance rate of over 80%, meaning that between the development sample and the test sample, each item had a strong completion rate; therefore, cross-validating the SDM-Q-9 items and the findings from the development group (Kriston et al., 2009). To score the Modified SDM Survey (Hrter & Scholl, 2018; Moyers et al. 2021), we summed the items leading to a raw total score between 0 and 45. We used the mean of the item scores to replace missing data if no more than two items were missing (Kriston et al., 2009). The calculation of a total score did not occur if more than two scores were missing (Kriston et al., 2009). Multiplying the raw score by 20 transformed the score into a range between 0 and 100, with 0 indicating a low level of SDM and 100 indicating a high level of SDM (Kriston et al., 2009). A previous rigorous literature review of relevant survey measures (Topp et al., 2018) found high construct validity of the Modified SDM Survey (Hrter & Scholl, 2018; Moyers et al. SHARED DECISION MAKING TRAINING EVALUATION 25 2021), excluding the SDM-Q9 (Kriston et al., 2009). There is no reliability established for these instrument items. In order to score item one about knowledge and three about who should make the treatment decision of the Modified SDM Survey (Hrter & Scholl, 2018; Moyers et al. 2021), we determined the mean responses, standard deviations (SD), and confidence intervals (CI). To score the fourth item, we calculated frequencies and means of the Likert scale for each identified barrier to SDM that remained after removing two barriers due to lack of relevance for this study. Data Collection To remove any conflict of interest, none of the students professors had knowledge of consenting participants names in the portion of the research study completed with the MOT and MSW students. Only one member of the research team was aware of the participants identifiable information and therefore was the designated research team member to be the single point of contact for the participants. This researcher also remained the main point of contact throughout the duration of data collection to maintain participant confidentiality, and to deidentify all collected data through the assignment of personal participant codes to each participant. This researcher met with the student study participants to review and electronically sign the consent form, and created a spreadsheet with participants names and code numbers in a Google Drive folder to which she only had access. Fellow researchers only viewed the data with the participants code numbers. The collection of student participant data occurred through six surveys completed through Qualtrics (https://www.qualtrics.com). The participants received a personal code to put on the surveys in place of their names. To ensure the surveys were correctly matched, participants had the option to put their initials because only one member of the research team had access to identifiable information. In addition, the same researcher was to obtain the site SHARED DECISION MAKING TRAINING EVALUATION 26 locations from the academic field coordinator for the social work students attending the joint course. This was to protect their confidentiality from the coordinator while still being able to obtain site permission for the student engagement in SDM at their site. Because the social work participant dropped out of this study, the researcher did not have to obtain any site locations. We sent information about the SDM experience, the tasks for the students, the need for the students to gain client consent to participate in the students learning activity about SDM, and the method of using the OPTION instrument to give feedback to all students enrolled in the MOT 505: Wellness in Occupation course. We emphasized that this activity would not affect the overall grade for the course. For consenting participants, we also sent information about the method for returning the completed OPTION scale. Researchers were available to the course instructor and students to answer questions about SDM at any time throughout the course. For the portion of this study completed with the IOTA participants, we obtained the participants consent through their participation in the initial survey on Qualtrics (https://www.qualtrics.com). The participants received a quick response (QR) code where they were able to access the survey digitally on their phone or computer. At the top of the pre-training survey, a statement informed the participants that their decision to complete both surveys indicated their consent to participate in the study. The participants had the option to create their own code, or use their initials if they felt comfortable doing so. We did not receive any identifiable data. In contrast to the MOT student participants, the IOTA participants completed only the pre and post SDM Knowledge and Attitudes Survey (Forcino, et al., 2018) and the Kirkpatrick Blended evaluation materials (Kirkpatrick & Kirkpatrick, 2016). SHARED DECISION MAKING TRAINING EVALUATION 27 Data Analysis With a variety of training assessments incorporated in this study, each evaluation method underwent separate data analysis. We imported all survey data into IBM SPSS Statistics (Version 28) for data analysis and set the alpha level of statistical significance at less than or equal to 0.05. SDM Knowledge & Attitudes Survey Using IBM 26th edition, we ran a mixed model analysis of variance (ANOVA) of the dependent variable SDM knowledge (Knowledge and Attitudes Survey; Forcino et al., 2018) because of the need to analyze the within-subjects effect of time (pretest and posttest) as a repeated measure, the between-subjects effect of participant groups (IOTA participants and the MOT/MSW participants), and the interaction effect between time and participant groups. The assumptions for the mixed model ANOVA were met including lack of significant outliers on SDM knowledge per participant group; and normal distribution of the dependent variable of SDM knowledge for each participant group. We did not evaluate sphericity, or the variances of the differences between time, the within-subject factor, for all participant groups of the betweensubjects factor, due to both the within and between groups having only two categories (Laerd, 2020). Consequently, we could assume sphericity. Participants had the choice to select I dont know as an option for the knowledge survey instead of selecting one of the Likert scale responses on the Knowledge and Attitudes Survey (Forcino et al., 2018). We ran a paired t-test to determine whether there was a change in I dont know scores from pretest to posttest for all participants. Questions eleven through twenty of the SDM Knowledge and Attitudes Survey (Forcino et al., 2018) explored the attitudes each participant had regarding SDM. We explored each Likert item through a calculation of the mean, standard deviations, and confidence intervals for all SHARED DECISION MAKING TRAINING EVALUATION 28 participants. Due to a number of missing values, we reviewed the data to assess the number of variables which were completed; and thus we calculated the mean based on 7 of the 10 variables as a replacement for each missing value (Laerd, 2020). Question 11 and 17 were reverse scored, meaning a response of a 3 and 4 were switched to a 2 or 1, respectively. This change allowed the participants to answer all the questions on the same scale with 1 being the most positive answer selection and 4 being the least positive answer. Assumptions for the attitude mixed model ANOVA were met, the within-subject component compared the change over time between preattitude and post-attitude scores for the entire sample. The between subjects factor analyzed the difference in the SDM attitudes between groups of participants. Because there were only two categories for both the within and the between factors (Laerd, 2020), we reported the interaction effect between time and groups for SDM attitudes as sphericity assumed. Modified SDM Post-Training Survey We collected data from the Modified SDM Survey (Hrter & Scholl, 2018; Moyers et al. 2021), which includes the SDM-Q-9 (Kriston et al., 2009) items, through Qualtrics (https://www.qualtrics.com). We reported means, standard deviations, and confidence intervals for the knowledge, SDM attitude, question two which was modified from the Control Preference Scale (Degner et al., 1997), and the SDM-Q-9 (Kriston et al., 2009) item. We reported the barriers to SDM implementation as frequencies as well as reported the mean, standard deviation, and confidence interval. We reported barriers to SDM implementation as a frequency of the barrier selected and as a mean of the Likert scores for each barrier. SHARED DECISION MAKING TRAINING EVALUATION 29 Kirkpatrick Blended Evaluation, Kirkpatrick Delayed Post-Training Survey, & OPTION Scale For the participant survey items of the Kirkpatrick Blended evaluation approach (Kirkpatrick & Kirkpatrick, 2016) for the MOT/ MSW and IOTA participants and the Kirkpatrick Delayed Post-Training survey (Kirkpatrick & Kirkpatrick, 2016) for MOT students only, we performed an item-by-item analysis of each Likert item through a calculation of the means, standard deviations, and confidence intervals for all participants. We analyzed the openended responses for themes. Likewise, we collected data from the OPTION scale (Elwyn et al., 2013) and analyzed the mean, standard deviation, and confidence intervals of adjusted scores for MOT participants. Program Effectiveness Table 3 lists the program outcome criteria as that Guild (1990) and Fink (2005) guided for each level of Kirkpatrick evaluation (Kirkpatrick & Kirkpatrick, 2016). Four outcome criteria were grouped together across levels one and two of the Kirkpatrick evaluation (Kirkpatrick & Kirkpatrick, 2016), and levels three and four had three outcome criteria each for a total of 10 program outcome criteria. We associated each outcome statement with a specific measurement tool and with a criterion for success for that individual outcome statement. To determine effectiveness per Kirpatrick level, participants met three out of four outcome statements for levels one through two, and two out of three outcome statements for levels three and four. We defined total effectiveness as two out of the three level groupings meeting criterion, with the added requirement that one of those groupings met be level three due to its connection to the transfer of training. SHARED DECISION MAKING TRAINING EVALUATION 30 Results Difference in Pretest and Posttest Knowledge and Attitudes Analysis of the knowledge and attitude survey involved analyzing the knowledge items and the attitude items separately to determine the overall improvement of each component of the survey. The knowledge and attitude components were also examined in terms of differences in participant groups, or the MOT/ MSW and the IOTA participants. We also determined interaction between time and participant group for the knowledge and for the attitude components of the survey. SDM Knowledge The knowledge portion of the survey (Forcino et al., 2018) included data from a total of 29 MOT/MSW and IOTA participants (Table 4). We excluded seven participants from data analysis, including the MSW student, because they filled out only the pre-training survey or only the post-training survey. We calculated the total scores of I dont know responses in the preknowledge data and compared that to the post-knowledge data using a paired t-test. There were 93 I dont know responses in the pre-knowledge compared to 22 in the post-knowledge data. We determined there was a significant difference between the pretest and posttest I dont know scores using a paired t-test, t (28) = 5.957, p = 0.000002. When comparing the pretest and posttest knowledge scores with a mixed model ANOVA, we did not assess Mauchlys test of Sphericity due to two categories each for the within and between factors (Laerd, 2020); however, the assumptions for the general linear model were met. Consequently we used sphericity assumed to interpret both the within subject effects for time and the interaction between time and group of participants. There were no influential outliers based on studentized residuals for both the pre-knowledge and post-knowledge data. SHARED DECISION MAKING TRAINING EVALUATION 31 Levene's test indicated equality of variance for the pre-knowledge scores as well as the postknowledge scores. There was a significant improvement in the post-knowledge scores, a main effect, following the SDM training with F (1, 20) = 21.31, p = 0.000167. This indicated that all participants positively improved from the pretest knowledge survey to the posttest knowledge survey. For the between factors analysis of the mixed model ANOVA, there was no difference in the knowledge scores between the two groups with F (1, 20) = .007, p = .932. There was no interaction effect between the two groups of MOT/MSW and IOTA participants and time, with F (1, 20) = .741, p = .400. SDM Attitudes The total pre-attitude and post-attitude portion of the survey (Forcino et al., 2018) included data from 29 MOT/MSW and IOTA participants (Table 5). There were six participants excluded from the data due to not completing both the pretest and posttest. We analyzed the data using a mixed model ANOVA to determine the effect time had on the pre-attitude data versus the post-attitude data for the sample. The assumptions for the general linear model were met. We chose not to test the sphericity assumption because there were two categories of data for both factors (Laerd, 2020). There were no influential outliers based on studentized residuals for both the pre-attitude and post-attitude data. Levene's test indicated equality of variance for the preattitude scores as well as the post-attitude scores. Using the mixed model ANOVA, we found a significant time difference between the pre-attitude scores and the post-attitude scores, with F (1, 22) = 24.51, p = .000059. There was no difference in attitudes regarding SDM between participant groups with F (1, 22) = .795, p = .382. There was no interaction effect of time and the MOT/ MSW and IOTA group as F (1, 22) = .102, p = .753. SHARED DECISION MAKING TRAINING EVALUATION 32 Summary of Statistical Analysis We found the mixed ANOVA tests indicated significant differences between the pretest and posttest knowledge and the attitude scores for the participant sample. In assessing the difference between MOT/MSW and IOTA participants, we used two mixed ANOVAs and found no differences in the two survey components for knowledge and attitude. There were no significant interaction effects between time and the knowledge and attitude scores of the two groups. Evaluation of SDM Differences between the MOT and IOTA participants Open-Ended Responses on Kirkpatrick Blended Evaluation Form Listed in Table 6 are specific quotes from both the IOTA and MSW/MOT participants on the Kirkpatrick Blended evaluation form. Both groups of participants did not provide any negative feedback about the training in their responses. Participants who attended our training presentation at the Indiana Occupational Therapy Association (IOTA) fall conference in 2021 offered alternative perspectives compared to the MOT/MSW students to the various items on the Kirkpatrick Blended Evaluation Form (Kirkpatrick & Kirkpatrick, 2016). When asked how they plan to apply SDM to their current or future jobs, the IOTA participants mentioned using the process to ensure they are engaging in evidence-based practice. Both groups of training participants had similar themes emerge when analyzing responses about anticipated outcomes of the SDM training; however, one anticipated outcome more often mentioned among the IOTA participants was that SDM could lead to more active participation from the client throughout the occupational therapy process (Table 6). The IOTA participants concluded that the SDM training helped them realize the importance of involving the client in the decision making process. SHARED DECISION MAKING TRAINING EVALUATION 33 The MOT and MSW students believed the training provided a structured format for them to collaborate with their clients. They also planned to apply this information to fieldwork by engaging in more open conversations with their clients. They did not note any additional resources needed for the training; however, several participants suggested providing this training to their future supervisors to increase the familiarity of clinicians with the topic. The students noted specific anticipated outcomes, such as increased client satisfaction and improved occupational performance. They expressed satisfaction with this training and indicated a desire to use SDM in the future with their clients. Quantitative Kirkpatrick Blended Evaluation Form We scaled the seven training-related likert questions on the Kirkpatrick Blended evaluation (Kirkpatrick & Kirkpatrick, 2016) on a 0 to 10 scale, with 0 being strongly disagree and 10 being strongly agree. Scores closer to 10 indicated that the participants agreed with the statement regarding the effectiveness of training as seen in Table 7. Question seven, I would recommend this program to my coworkers or classmates, had a mean score of M = 9.14, SD = .727, and 95% CI [8.81-9.47], which translates for most participants as a strongly agree response. Study participants indicated a strong level of confidence in applying the knowledge gained about SDM in their clinical settings or educational experience with M = 8.24, SD = 1.261 and 95% CI [7.66-8.81], which translates to a high level of agreement. Furthermore, the participants had a high level of commitment to the application of SDM to their clinical setting in the future, with M = 8.33, SD = 2.153 and 95% CI [7.35-9.31]. SHARED DECISION MAKING TRAINING EVALUATION 34 MOT Student Results on Modified SDM Survey Open-Ended Responses on the Modified SDM Survey For the Modified SDM Survey (Hrter & Scholl, 2018; Moyers et al., 2021) and the Kirkpatrick Delayed Post-Training Survey (Kirkpatrick & Kirkpatrick, 2016), there were optional comment sections that offered participants the opportunity to provide additional information regarding their responses. Due to the small sample size and small number of openended responses, we did not code this data. Quantitative Results for the Modified SDM Survey The first Likert question in the Modified SDM Survey (Hrter & Scholl, 2018; Moyers et al. 2021) determined the participants overall knowledge about SDM. With 10 meaning the participant understands all aspects of SDM and 1 indicating no knowledge on the subject, the scores for the MOT participants were M = 7.29, SD = 1.38 and 95% CI [6.01-8.56]. Thus, the participants reported having a moderately high knowledge about SDM. Furthermore, the participants' response on question two modified from the Control Preference Scale (Degner et al., 1997) indicated the therapist and client should make the decision together as opposed to the therapist dictating the clients outcome or the patient making the decision without the therapist's input (Table 9). The higher mean on questions five through 13 indicates the better score on the SDM- Q9 (Table 9) with 1 being completely disagree and 6 being completely agree. Question 10, for example, examines if the student asked their patient which treatment option they preferred. Most of the participants selected agree for that statement with M = 5.29, SD = .756, 95% CI [4.595.98]. Similar to question 10, most SDM-Q9 (Kriston et al., 2009) responses were agree or completely agree except for question eight, which had a lower mean compared to the other SHARED DECISION MAKING TRAINING EVALUATION 35 questions. Question eight asked if the advantages and disadvantages of each treatment option were precisely explained to the client. The mean response for this question was M = 3.71, SD = .765, 95% CI [3.02-4.41], which fell between the somewhat disagree, labeled as 3, and somewhat agree, labeled as 4, Likert responses on the survey. Question eight has a wider confidence interval range of 1.39 compared to the other question responses, which indicates uncertainty surrounding the point estimate for the mean. The researchers recorded the barriers to SDM implementation as means and as frequencies of the most selected response on the Likert scale for each barrier as indicated on Table 10 for questions 14 to 21. The barriers were recorded as means and frequencies due to the low number of individuals in the sample (Hrter & Scholl, 2018; Moyers et al., 2021). Because two barriers were removed due to lack of relevance to this study, the student participants used a 6-point likert scale to select a response for six barriers. The lower the mean, the more favorable because the list of barriers were not as challenging to overcome. The students reported these barriers as not inhibiting the treatment session. Question 14, lack of time hinders or hindered me to actively involve clients in decision making had a large confidence interval of 2.14 with M = 3, SD = 1.16, 95% CI [1.93 - 4.07]. The average response correlates to somewhat disagree; however, the most frequently reported response was strongly disagree. The variability in responses is due to the high level of uncertainty surrounding the confidence interval estimation. Question 18 demonstrated the widest range of responses, clients do or did not want to participate in decision making, had a variety of responses with two participants selecting strongly disagree, two participants selecting somewhat agree, and one participant selecting one of the following options: completely disagree, somewhat SHARED DECISION MAKING TRAINING EVALUATION 36 disagree, strongly agree. However, the average response for question 18 was somewhat disagree with M = 3.00, SD = 1.41, 95% CI [1.69-4.31]. The MOT students were knowledgeable about SDM as seen in question 20 regarding SDM barriers, I lack or lacked knowledge on how to actively involve clients in decision making (Hrter & Scholl, 2018; Moyers et al., 2021). With an average response of strongly disagree, M = 2.71, SD = .756, 95% CI [2.02-3.41], the participants did not perceive any lack of knowledge on their part as a barrier to implementing SDM with their clients. Question 21, it makes no sense to actively involve clients in decision making, had the lowest recorded average for the list of barriers with M = 1.57, SD = .54, 95% CI [1.08-2.07] (Table 10). The most frequently reported response for question 21 about barriers was strongly disagree which corresponds to the low mean. In fact, three barrier questions, questions 19-21, had average responses that corresponded to the highest frequency of participants reporting the barrier as an issue for them. MOT Student Results on Kirkpatrick Delayed Post-training Survey Open-responses on Kirkpatrick Delayed Post-Training Survey For the Kirkpatrick Delayed Post-Training Survey (Kirkpatrick & Kirkpatrick, 2016), participants provided feedback on their knowledge of expectations after the training, whether they successfully applied what they learned in training, and any suggestions to improve the applicability of the training materials. The majority of the participants believed that they understood the expectations of them after the training; however, several participants noted that receiving additional instruction on the SDM implementation process with their CPRG client during their MOT 505: Wellness in Occupation course would have been helpful, even though they had access to training resources after the training. They also wanted a second review of the study requirements to remind them of the expectations for the research study closer to their SHARED DECISION MAKING TRAINING EVALUATION 37 intervention session with their CPRG client. Additionally, one participant noted that other stressors associated with being in a graduate program impacted their ability to remember the expectations of them for the purpose of this study. Many of the participants also believed they successfully applied what they learned in the training with their CPRG client and that the training itself significantly contributed to their ability to apply what they learned. Many also found it beneficial that they were able to refer back to the training resources we provided when needed. Two participants provided constructive feedback on how to improve the applicability of our training materials. Both noted that having the training occur closer to the time of application would be beneficial. One participant discussed including additional mandatory assignments, as they lacked the motivation to look through the optional SDM resources that we provided. Overall, participants of this study provided positive feedback on the training and had positive perceptions of their ability to apply the concepts with their assigned client. Quantitative Kirkpatrick Delayed Post-Training Survey Participants selected values on the likert scale from 1, strongly disagree, to 4, strongly agree, with responses closer to 4 being ideal for the quantitative Delayed Kirkpatrick survey data found in Table 11. The average response for each question on the survey was at least agree, indicating satisfaction with the training. Specifically, three questions highlighted the positive effects of the training: question four, I am successfully applying what I learned in the training, with M = 3.67, SD = 1.464 and 95% CI [1.79 - 4.50]; question eight, I am already seeing positive results from this training with M = 3.14, SD = .69, 95% CI [2.5 - 3.78]; and question nine, I am expecting positive results from this training in the future, with M = 3.29, SD = .49, SHARED DECISION MAKING TRAINING EVALUATION 38 95% CI [2.83-3.74]. Nearly all participants strongly agreed that they were successfully applying what they learned in the training in the clinical experience with the CPRG clients. MOT Student Results on the OPTION Scale Out of the participants who completed the OPTION scale (n = 6), four out of six of the participants scored a 90 out of 100 or higher, one participant scored a 75 out of 100, and one participant scored a 20 out of 100, with an overall result of M = 79.17, SD= 30.23 and 95% CI [47.44-110.90]. This is a wide confidence interval, indicating variability in the mean. Training Protocol Effectiveness Guild (1990) and Fink (2005) provided guidance in how to develop criterion for determining program effectiveness. The researchers used this guidance, in accordance with the Kirkpatrick and Kirkpatrick Levels of Evaluation (2016) and the associated measurement tool, to develop specific criterion to determine if the SDM training was an effective training protocol. The first criterion included survey outcomes from Kirkpatrick levels one and two, the second criterion included survey outcomes from level three, and the third criterion included survey outcomes from level four. Criterion one included four survey outcomes, and criterion two and three each included three survey outcomes. Each survey outcome as indicated had a separate criterion to determine if the program was effective per outcome. For example, the first outcome listed under the first criterion stated, the learner demonstrated improved knowledge of shared decision making. To measure this outcome, the researchers compared the pre and posttest knowledge scores on the SDM Knowledge and Attitudes Survey (Forcino et al., 2018). The criterion for this outcome was met if the participants in the program received a significantly higher knowledge score on the posttest SHARED DECISION MAKING TRAINING EVALUATION 39 compared to their baseline knowledge score. Each criterion for their associated outcomes and measurements used to determine effectiveness can be found in Table 3. Criteria were also set to determine total program effectiveness. To meet criterion one for program effectiveness, the participants had to achieve three out of the four outcomes criteria. To meet criterion two and three, the participants had to achieve two out of the three outcome criteria. The SDM training was considered effective if the participants achieved at least two of the three criteria. Also, one of the two criterion met had to be criterion two, due to its connection to the transfer of training (Kirkpatrick & Kirkpatrick, 2016). Kirkpatrick Level One and Two Participants of this study met all four outcomes for the reaction and learning evaluations from Kirkpatricks approach to training evaluation within the first criterion (Kirkpatrick & Kirkpatrick, 2016). The sample post-training SDM knowledge scores were significantly higher than the pre-training scores, indicating improved knowledge scores. There was a significant difference between pre-training and post-training attitude scores as well. Thus, the participants improved their attitude toward SDM following the training. The average response for the confidence and commitment question met the requirement with the average response of M = 8.24, SD = 1.26, 95% CI [7.66-8.81] surpassing the 8 out of 10 criterion for this outcome (Table 3). Therefore, the participants met the overall criterion for Kirkpatrick Levels one and two as four out of four outcome criteria within the first criterion for training effectiveness were achieved. Kirkpatrick Level Three The participants met the second criterion achieving two out of the three outcome criteria associated with Kirkpatrick level three. This result determined the programs effectiveness in SHARED DECISION MAKING TRAINING EVALUATION 40 producing successful transfer of knowledge of participants to future clinical situations. The participants provided positive feedback and believed the training was effective for shared decision making with the average response of M = 3.14, SD = .69, 95% CI [2.50-3.78] meeting the first outcome criteria of at least a three out of four. The participants reported successfully transferring knowledge from training to implementation with CPRG clients with an average response out of four with M = 3.67, SD = 1.46, 95% CI [1.79-4.50]. Therefore, the average response to these questions met the second outcome criteria the researchers developed as participants scored at least a three out of four (Table 3). The third outcome criteria was not met due to the lack of responses to the expectation and application question received from participants. Despite this, the participants still achieved the second program effectiveness criterion because two out of three outcome criteria were met. Kirkpatrick Level Four Participants were unable to meet the third criterion associated with Kirkpatrick level four outcome criteria (Table 3). The five items from the OPTION scale were totaled and rescaled to fit a zero to 100 point scale. The first outcome criteria required at least 80 percent of participants to score an 80 out of 100 or better on the OPTION scale. On the OPTION scale, there were 66 percent of participants who achieved an 80 out of 100. The second outcome criteria required 80 percent of participants to score at least a 7 out of 10 on the Modified SDM Survey knowledge question (Hrter & Scholl, 2018; Moyers et al. 2021). This outcome criteria was not met because only 71 percent of participants met the 7 out of 10 or higher requirement on the knowledge question (Table 3). The last outcome criteria within the third criterion required 80 percent of the participants to acknowledge client decision making as important to client-centered practice. This SHARED DECISION MAKING TRAINING EVALUATION 41 outcome criteria was met, as 85 percent of participants acknowledged the importance of clinical decision making in their survey. Total Program Effectiveness Results To determine total program effectiveness, the researchers analyzed the number of level criteria the participants met after completion of all evaluation methods. For the SDM training to be considered an effective program, the participants had to meet two out of three level criteria that the researchers defined for program effectiveness. The participants met this requirement, meeting the first and second level criteria. This indicates that the SDM training was an effective program for the participants. Discussion SDM Knowledge and Attitudes Pre- and Post- Training The IOTA and MSW/MOT participants both demonstrated a significant increase in their post-knowledge scores and a significant decrease in the I dont know portion of the SDM Knowledge and Attitudes Survey (Forcino et al., 2018) following the SDM training. This indicates that engagement in the SDM training led to an increase in knowledge for both participant groups. There was also a significant improvement in the attitudes pre and posttest for both participant groups in this study. This data aligns with findings from Hoffmann et al. (2014) who found improvements in students attitudes towards the use of SDM after their participants engaged in a brief SDM intervention, as well as improvements in confidence levels of the students after participation in the SDM intervention. The findings of our research study are also consistent with findings from Durand et al. (2018). Durand et al. (2018) performed a scoping review to analyze research regarding training on SDM (2018). In the majority of the studies, they SHARED DECISION MAKING TRAINING EVALUATION 42 found that students skills and confidence in SDM significantly increased post-training (Durand et al., 2018). Differences in Knowledge and Attitudes Towards SDM Between IOTA and MSW/MOT Participants There was no difference in knowledge scores between the MOT/MSW groups and the IOTA participant group. Both the MOT/MSW students and the IOTA participants demonstrated a change in attitudes toward SDM between pretest and posttest; however, we did not find an interaction effect between time and group attitude scores to determine if there was a difference between groups. We were unable to identify current literature evaluating a difference in knowledge and attitudes towards SDM between students and practitioners, indicating a need for further research on the topic. We did, however, find evidence supporting the lack of SDM training for both healthcare professionals and students indicating that SDM may be a novel topic for both these groups (Hoffmann et al., 2014; Goto et al., 2022; Moore et al., 2018). Goto et al. (2020) noted that there are currently no SDM courses included in the curricula for medical or nursing students and there is little effort to promote SDM at organizational or regional levels (2022). Moore et al. (2018) discussed that even though the small number of existing SDM training programs help clinicians develop SDM skills and attitudes, the translation to practice will not occur unless organization and administrative leaders demonstrate their support for SDM through integration into their practices. They also note that further research is needed to evaluate effective implementation strategies for healthcare professionals (Moore et al., 2018). Our study contributes to this need as we provide evidence supporting practitioner and student outcomes upon completion of an effective SDM training program. SHARED DECISION MAKING TRAINING EVALUATION 43 Kirkpatrick Blended Evaluation Responses We gained valuable insight from both the IOTA and MOT/MSW student participants on the Kirkpatrick Blended evaluation (Kirkpatrick & Kirkpatrick, 2016). First, we found the MOT/MSW students believed that practicing clinicians need continued education regarding SDM concepts. Previous researchers have communicated similar findings (Durand et al., 2018; Hoffmann et al., 2014). Hoffmann et al. (2014) detailed that without specific training on SDM, health professional students graduate with communication skills that are not sufficient enough to cover the principles of SDM. Durand et al. (2018) detailed that adoption of SDM across practice settings is unlikely without sufficient training or adequate clinician knowledge about SDM. Hoffmann et al. (2014) emphasized the need for routine clinical training in SDM and the need for continuing professional development on this topic. Without properly educating current clinicians in the field on this topic, there could be a lack of supervisors who are able to provide adequate feedback and guidance to occupational therapy students on fieldwork rotations who are attempting to implement SDM in practice. This fieldwork supervision issue emphasizes the importance and need for quality SDM training materials for both students and practicing clinicians. The IOTA participants believed that practicing SDM ensures that occupational therapists are engaging in evidence-based practice. Many of the IOTA participants were currently practicing as occupational therapists, which matters because it conveys positive attitudes towards SDM from current clinicians and demonstrates their accurate perception of the relationship between SDM and evidence-based practice. They also stated that there is a need for additional research on SDM with clients in the healthcare setting and education. They did not specify what areas of SDM, but emphasized a general need for additional research on this topic. This response SHARED DECISION MAKING TRAINING EVALUATION 44 is meaningful as it shows participant awareness of the significance of SDM research. This recognition of importance is similar to findings from previous researchers as well (Durand et al., 2018; Hoffmann et al., 2014; Butow et al., 2014). Durand et al. (2018) specified the need for additional research on information retained from SDM training once students enter into practice in order to increase transferability. These researchers mentioned that additional research on this topic would be beneficial to gain a better understanding on whether SDM training affects students knowledge, attitudes, and beliefs once they enter practice as a healthcare professional (Durand et al., 2018). Hoffmann et al. (2014) also emphasized the need for further research on the long-term effects of SDM training when incorporated into evidence-based practice courses for students. These findings demonstrate the gaps in knowledge that still exist when transfering SDM into practice. The IOTA and MOT/MSW participants collectively offered their perspective about the anticipated outcomes of using SDM in practice. Both groups anticipated when using SDM, there would be an increase in client satisfaction, occupational performance, and active participation. These findings matter because it demonstrates the positive perception of SDM outcomes when incorporated into practice. Durand et al. (2018) also stated that SDM allows clients to become more actively involved in their healthcare. Butow et al. (2014) found in their randomized control trial supported the use of SDM approaches to improve patient and doctor outcomes. These findings validate our participants perceptions of possible SDM outcomes. MOT Results from Modified SDM and Delayed-Post Training Surveys The MOT student performance on the Modified SDM Survey (Hrter & Scholl, 2018; Moyers et al., 2021) indicated that they had moderately high knowledge of SDM after completing the training. The mean score of the knowledge question on the survey was above SHARED DECISION MAKING TRAINING EVALUATION 45 average for knowledge on the topic of SDM. They had a neutral response on the survey item regarding their ability to thoroughly explain the advantages and disadvantages of various treatment options to their client. This difficulty in explaining treatment options may be due to their lack of knowledge of treatment options for specific conditions or decreased confidence as it was still early in their occupational therapy program. In addition, the researchers did not include a role play demonstration using the Ottawa Personal Decision Guide (OConnor et al., 2015) in the student presentation as detailed on page 17. This role play demonstration could have aided their understanding and improved their confidence in explaining appropriate treatment options to their CPRG clients. Barriers to SDM from Modified SDM Survey The MOT students experienced various barriers while implementing SDM with their CPRG clients. Although the average response to question fourteen, lack of time hinders or hindered me to actively involve clients in decision making, was somewhat disagree. The high mean M = 3, SD = 1.16, 95 CI [1.39-4.07] demonstrates a wide range of responses. Some participants found time to be a barrier when engaging in the SDM process with their CPRG clients. In a systematic review, Waddell et al. (2021) found that time was a barrier for practitioners to consistently include SDM into conversations with clients. In addition, the American Occupational Therapy Association (AOTA) supports SDM as a way to engage in evidence-informed interventions as noted in the Choose Wisely campaign (American Occupational Therapy Association [AOTA], 2022) . Researchers who conducted a study related to the campaign found handouts are useful tools for health education and decision making in the SDM process (Cahill & Richardson, 2022). However, without formal training that is routinely SHARED DECISION MAKING TRAINING EVALUATION 46 taught and modeled the use of resources and tools will not reduce barriers practitioners experienced in the clinical setting (Schoenfeld et. al, 2018, p. 43). The MOT participants agreed that clients should be included in the SDM process, but responses to question eighteen on the Modified SDM Survey indicated an additional barrier was the variability of the clients willingness to participate in SDM. This could be due to the experience with the CPRG clients being the students first time engaging clients in SDM. According to Moleman (2021), there is a need for a more nuanced understanding of SDM as a graded framework that allows for flexibility in the decisionmaking style to accommodate a patient's unique preferences and needs (p. 932). As the MOT students gain additional experience engaging clients in SDM, they may become more confident in their ability to identify their clients preferred learning style and communication needs. Delayed Post-Training Survey Results from the Delayed Post-Training Survey indicated participant satisfaction with the training. Almost all of the participants had strong agreement that they were successfully applying what they learned, seeing positive impacts, and expecting to see additional positive impacts from the training in the future. These statements further demonstrate the participants attitudes towards the training and how meaningful they found it to be. Despite the participants strong perception that they were successfully applying what they learned, two of five participants scored a 75/100 or worse on the OPTION scale. This indicates that some participants had higher confidence in their ability to apply SDM than their actual ability to do so. These findings are similar to those of Hoffmann et al. (2014), who found that their participants confidence in their ability was higher than their baseline scores on the OPTION scale. Hoffmann et al. notes that healthcare professionals are frequently overconfident about their communication skills and do not perceive SHARED DECISION MAKING TRAINING EVALUATION 47 training on this topic to be useful; however, when assessed on these skills, they often perform poorly (Hoffmann et al., 2014). The researchers believe communication is not a skill that is further developed with time and experience, so skilled training in this area is warranted (Hoffmann et al., 2014). Our findings suggest the same, as some of our participants had inaccurate perceptions of their own ability to apply SDM concepts in practice. Qualitative Feedback on Modified SDM Survey The MOT student participants also offered qualitative feedback on the Modified SDM Survey (Hrter & Scholl, 2018; Moyers et al., 2021) and the Delayed Post-Training Survey (Kirkpatrick & Kirkpatrick, 2016). The students believed that a refresher course closer to application would have improved their ability to complete the transfer of learning activity. Butow et al. (2014) offered similar feedback after performing their SDM training. They stated that communication skills training lasting at least three days in length has been proven most effective compared to those shorter in length (Butow et al., 2014); however, they described that designing effective workshops is difficult when also considering the time constraints many clinicians experience (Butow et al., 2014). As a solution, they suggested shorter, but more frequent sessions as an effective way to deliver educational training (Butow et al., 2014). The MOT participants also believed having access to the training resources after the training session contributed to their ability to successfully apply what they learned. They appreciated being able to refer back to resources to refresh their knowledge prior to engaging in their application of learning with clients. Overall, these findings provide further insight about the effectiveness of our training and what future training methods should include for optimal transferability to practice. SHARED DECISION MAKING TRAINING EVALUATION 48 OPTION Scale Results The results on the OPTION Scale indicated that four out of the six participants engaged their CPRG client in the decision making process of their intervention sessions to an exemplary degree of effort, one at an average level, and one at a below-average level. These results indicate that with provided training and resources, more than half of the participants were able to involve the patient in shared decision making regarding their intervention options. There are several possibilities as to why two of the participants scored lower on the OPTION scale. First, the students were not graded academically for their engagement in SDM with their CPRG client. It was a low stakes experience, so they may not have put forth as much effort. Perhaps a more intensive, graded experience would have motivated the two students to try harder during the implementation practice. A second possibility for low OPTION scores involves the length of time between the training and application of knowledge experience with the CPRG client. Future research is needed on transfer of knowledge with the application closer to the time of the training. Lastly, the students were under time restraints during their encounters with their CPRG client. Each student had limited time for their evaluation and treatment session, which may have impacted their ability to fully implement SDM during the allotted time period. Offering more time for each evaluation and intervention session may have improved student participant scores. Other researchers have examined participant knowledge of SDM with the use of the OPTION scale as well (Hoffman et al., 2014, Menear et al., 2018, Cout et al., 2015). Hoffmann et al.(2014) used the OPTION scale as their primary outcome measure for their participants. The authors noted that the OPTION scale does not specifically evaluate a persons ability to communicate evidence, so they also used items from the Assessing Communication about Evidence and Patient Preferences (ACEPP) Tool (Hoffmann et al., 2014). We did not use a SHARED DECISION MAKING TRAINING EVALUATION 49 separate tool to evaluate our participants ability to explain evidence to their patients. The participants in the study completed by Hoffmann et al.(2014) scored significantly higher on the OPTION scale post intervention. These high OPTION scale scores may be attributed to the researchers undergoing a more in-depth training on the scoring protocol prior to reviewing the role play interactions (Hoffmann et al., 2014). Menear et al. (2018) also used the OPTION scale as an outcome measure in their study on SDM. They observed low OPTION scale scores amongst the physicians and attributed this to several factors (Menear et al., 2018). First, they noted the OPTION scale is often criticized for including certain behaviors that are not commonly observed in practice, which can lead to floor effects (Menear et al., 2018). They also discussed that high scores on the OPTION scale are possible when individuals have additional experience in SDM (Menear et al., 2018). Cout et al. (2015) performed a systematic review to determine the use of SDM among healthcare providers using the OPTION scale. They found that OPTION scale scores were lowest among healthcare professionals who had not received prior training in SDM (Cout et al., 2018). They found higher OPTION scale scores when consultation time was longer between the patient and the provider (Cout et al., 2018). They also found improvements in OPTION scale scores over time as providers underwent training in SDM and were given time to implement the concepts into practice (Couet et al., 2018). Kirkpatrick Outcome Levels Overall Effectiveness The participants of this study met the criterion requirement defined for effective program development, indicating that our SDM training is considered an effective training program. The effectiveness of this training program can be attributed to several factors. Firstly, the use of the SHARED DECISION MAKING TRAINING EVALUATION 50 six disciplines prompted a thorough development of each aspect of the training (Pollock et al., 2015). This first discipline included pre training materials and expectations, didactic content, role play opportunities, post training materials, and an opportunity for application. We designed our training with a focus on the transfer of knowledge after training, as little to no research currently exists on actual transfer of training to practice. The effectiveness of our training program can also be attributed to our extensive number of outcome measures. We used Kirkpatricks (Kirkpatrick & Kirkpatrick, 2016) approach for evaluating training and educational programs through four levels of training evaluations. Within each evaluation level, we incorporated at least one evidenced-based outcome measure to gather reliable and valid data from our participants, as our evaluation methods were both reliable and valid. Our rigorous approach differs from existing literature on SDM training protocols. Goto et al. (2022) similarly used Kirkpatricks (Kirkpatrick & Kirkpatrick, 2016) approach for training evaluations to evaluate their SDM training. The evaluation of their participants took place immediately after training, so they were only able to use Kirkpatricks levels one through three to evaluate their participants (Kirkpatrick & Kirkpatrick, 2016). They also used the SDM-Q9 (Kriston et al., 2009) to evaluate participant knowledge of SDM; however, they developed their own questionnaires to evaluate participant attitudes (Goto et al., 2022). Additionally, Goto et al. (2022) did not develop criteria for an effective training program, but instead based their effectiveness on the pre and post knowledge and attitudes scores. Other researchers have also based training effectiveness solely on pre-post knowledge and attitudes scores (Butow et al., 2014, Durand et al., 2018), which we believe is an insufficient representation of training effectiveness as it does not consider the transfer of knowledge posttraining. SHARED DECISION MAKING TRAINING EVALUATION 51 Hoffmann et al. (2014) also studied the effectiveness of a SDM training program using evidenced-based outcome measures like the OPTION Scale. They note having no data on the transfer of knowledge over time and not using real patients as limitations to their study (Hoffmann et al., 2014). We addressed both of these limitations in our study, evaluating transfer of knowledge almost six months after training and including real, CPRG clients for the application opportunity. Our research contributes to the gaps in knowledge currently found in the literature regarding effective training programs. Our extensive process to develop and evaluate this training program coupled with our positive participant outcomes convey its groundbreaking contribution to the literature surrounding effective SDM training and implementation for students and practitioners. Limitations Our small sample sized limited evaluation of the training. The small MOT/MSW class size limited our ability to recruit a large participant sample. A small sample size can increase the risk for Type II errors; however, we found that the small class size allowed for more participant involvement and greater opportunities for detailed role playing. Regarding the MSW students, we recruited one participant who dropped out early during the study. However, this drop in student sample size motivated us to recruit IOTA fall conference attendees as additional participants. This increased the sample size and allowed us to compare data between occupational therapy students and current practitioners in the field. Another limitation was the addition of an I dont know option to each statement within the SDM Knowledge and Attitudes Survey as the authors of the survey had recommended (Forcino et al., 2018). This addition could have changed the validity of the instrument as scoring of the I dont know option was unclear (Groothuis & Whitehead, 2002). However, the validity of SHARED DECISION MAKING TRAINING EVALUATION 52 the instrument did not seem to affect the interpretation of our results as we found both a significant difference between pretest and posttest knowledge scores along with a significant decrease in the I dont know scores at posttest. Additionally, reliability has not been established for this instrument. Application to Occupational Therapy Incorporating SDM into the occupational therapy curriculum is vital to the prospective use of SDM within the healthcare field. Having background knowledge in SDM may lead to better attitudes towards its use in practice. Lack of SDM knowledge can lead to poor outcomes in regards to client-centered care (Hughes et al., 2018). Creating the opportunity for the client to be an active participant in their intervention selection is important to client-centered practice and occupational therapys emphasis on evidence-based practices and the connection to using practice guidelines as the basis for offering (AOTA, 2020). Evidence-based practice and the connections built can lead to better adherence to the chosen treatment plan and may contribute to better intervention outcomes (Pollock et al., 2015). Recommendations for Application to Occupational Therapy Future research should include the replication of the present study with a larger sample size to decrease the influence of outliers in smaller sample sizes as well as increase the reliability of the results. To increase the participants confidence in transfer of learning, we recommend reducing the time gap between the SDM training and application of the learned material. Additionally, we recommend implementing a review session between the SDM training and the implementation with clients. In future research, participants should complete the Knowledge and Attitudes Survey (Forcino et al., 2018) at the end of clinical work to determine if knowledge of SDM improves, maintains, or declines from the time between training and the end of the clinical SHARED DECISION MAKING TRAINING EVALUATION 53 experience. The inclusion of this survey would also inform future researchers of any attitude changes towards SDM, whether positive or negative. If future studies show that occupational therapists have negative attitudes towards SDM, we recommend the implementation of an assessment of client satisfaction. An increase in client satisfaction due to the use of SDM in clinical work would increase the likelihood practitioners would continue their use of SDM following the study completion. We recommend that clinicians practice an evidence-based treatment approach during treatment sessions, such as using the Ottawa Personal Decision Guide (OConnor et al., 2015). This guide helps ensure that the clinician is using treatment approaches guided by recent evidence and that the client has autonomy in every step of their treatment plan, further reducing barriers to the SDM process. We recommend inclusion of SDM into occupational therapy curricula and integration through multiple courses for application, as it currently is not in many programs (Hoffmann et al., 2014). Integrating SDM into OT curricula would increase opportunities for students to apply what they learned in class and on fieldwork with clients, reducing the barriers the MOT students experienced when engaging the CPRG clients in SDM for the first time. Additionally, once in practice, clinicians should receive continuing education on SDM to learn how to tailor their intervention plans to the specific needs of their clients (Smith, 2016). In regards to curricular threads and enhancing learning about SDM in the classroom, we also recommend that further research addresses how SDM can be applied with individuals with cognitive disabilities or in the mental health setting. Individuals in these populations may not be able to actively participate in SDM in the same way that others would. Finally, future research should also cross more SHARED DECISION MAKING TRAINING EVALUATION 54 disciplines to increase the literature available on the use of SDM from an interdisciplinary perspective. Conclusion Shared decision making encourages clients to manage their health choices and facilitates practitioner engagement in evidence-based practice. Lack of SDM practice and education may lead to poor results regarding client outcomes and involvement. The implementation of SDM training and continued education does improve client-centered practice, enhance intervention outcomes, and increase client participation. The study identified a growing need within the education curriculum and healthcare practice to enhance client engagement when making decisions regarding intervention strategies. The difference between practitioners and healthcare students knowledge, attitudes, and beliefs of SDM pre-training and post-training within this study have shown that there is an additional need for advanced research and application of SDM in the educational and clinical settings. SHARED DECISION MAKING TRAINING EVALUATION 55 References American Occupational Therapy Association [AOTA]. (2022). AOTAs Choosing Wisely Champion Campaign. 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Physical Therapy, 98(12), 10221036. https://doi.org/10.1093/ptj/pzy095 Moyers, P., Gettinger, A., Slusser, A., Grubbs, T., Jones, R., Beneker, H., & Bentley, J. (2021). Knowledge and use of shared decision making of occupational therapists in clinical practice: A survey study. School of Occupational Therapy, University of Indianapolis, Indianapolis, IN, United States. Moyers, P.A, Herrmann, M.E., Viewegh, Z.T., Crispen, L.M., Hudson, S.E., Smith, K.H, & Kilbride, A. L. (2020). Shared decision making training effect on knowledge, skills, and attitudes: A Systematized review [Unpublished manuscript]. School of Occupational Therapy, University of Indianapolis. O'Connor, Stacey, & Jacobsen. (2015). Ottawa Personal Decision Guide. Ottawa Personal Decision Guides. Retrieved February 27, 2022, from https://decisionaid.ohri.ca/docs/das/OPDG.pdf Osmosis. (2018). Shared Decision Making. YouTube. Retrieved April 1, 2022, from https://youtu.be/4ueDJEFytMI. Ospina, N. S., Toloza, F. J.K., Barrera, F., Bylund, C. L., Erwin, P. J., & Montori, V. (2020). Patient Education and Counseling: Educational programs to teach shared decision making to medical trainees: A systematic review. Patient Education and Counseling, 103(6), 1082-1094. https://doi.org/10.1016/j.pec.2019.12.016 Pollock, R. V. H., Jefferson, A., & Wick, C. W. (2015). The Six Disciplines of Breakthrough Learning: How to Turn Training and Development into Business Results (3rd ed.). Pfeiffer. SHARED DECISION MAKING TRAINING EVALUATION 60 Schoenfeld E.M., Goff S.L., Elia T.R., Khordipour E.R., Poronsky K.E., Nault K.A., Lindenauer P.K., Mazor K.M. (2018) A Qualitative Analysis of Attending Physicians' Use of Shared Decision-Making: Implications for Resident Education. J Grad Med Educ. 10(1), 43-50. http://doi.org/10.4300/JGME-D-17-00318.1 Smith, M.A., (2016). The Role of Shared Decision Making in Patient-Centered Care and Orthopaedics. Orthopaedic Nursing, 35(3), 150151. https://doi.org/10.1097/nor.0000000000000251 Stiggelbout, A., Pieterse, A., & De Haes, J. (2015). Shared decision making: Concepts, evidence, and practice. Patient Education and Counseling, 98(10), 1172-1179. https://doi.org/10.1016/j.pec.2015.06.022 The Ottawa Hospital Research Institute. (n.d.). A to Z Inventory of Decision Aids. Patient Decision Aids. Retrieved February 27, 2022, from https://decisionaid.ohri.ca/AZinvent.php Topp, J., Westenhfer, J., Scholl, I., & Hahlweg, P. (2018). Shared decision-making in physical therapy: A cross-sectional study on physiotherapists knowledge, attitudes and selfreported use. Patient Education and Counseling, 101(2), 346351. https://doi.org/10.1016/j.pec.2017.07.031 Volk, R. J., Shokar, N., Leal, V., Bulik, R. J., Linder, S., Mullen, P.D., Wexler, R.M., & Shokar, G. (2014). Development and pilot testing of an online case-based approach to shared decision making skills training for clinicians. BMC Medical Informatics and Decision Making, 14(1), 95. https://doi.org/10.1186/1472-6947-14-95 SHARED DECISION MAKING TRAINING EVALUATION 61 Waddell, A., Lennox, A., Spassova, G., & Bragge, P. (2021). Barriers and facilitators to shared decision-making in hospitals from policy to practice: a systematic review. Implementation Science, 16(74), 1-23. https://doi.org/10.1186/s13012-021-01142-y Yap, G., Joseph, C., & Melder, A. (2019). Shared decision making training programs for doctors: A Rapid Review. Monash Health: Centre for Clinical Effectiveness, 1-16. https://monashhealth.org/wp-content/uploads/2019/06/SDM-Rapid-Review-Final010319.pdf SHARED DECISION MAKING TRAINING EVALUATION 62 Table 1 Content used During SDM Presentations Training Tools Name of Tool Citation/Hyperlink Osmosis SDM Video https://youtu.be/4ueDJEFytMI SDM Pocket Card Braddock, C., Hudak, P. L., Feldman, J. J., Bereknyei, S., Frankel, R. M., & Levinson, W. (2008). surgery is certainly one good option: Quality and time-efficiency of informed decision-making in surgery. The Journal of Bone and Joint SurgeryAmerican Volume, 90(9), 18301838. https://doi.org/10.2106/jbjs.g. 00840 Elwyn, G., Tsulukidze, M., Edwards, A., Lgar, F., & Newcombe, R. (2013). Using a talk model of shared decision making to propose an observation-based measure: Observer OPTION5 Item. Patient Education and Counseling, 93(2), 265271. Option Scale Ottawa Personal Decision Guide https://decisionaid.ohri.ca/docs/ das/opdg.pdf Content Introductory information on SDM SDM checklist items, and additional questions to prompt use of SDM in practice When was it used during the training? Used video as a pre-training introduction to SDM Included a tools for implementation section within the training to introduce this tool Five descriptive Included a tools for statements that an implementation section individual can use within the training where to reflect on their to introduce this tool. ability to implement Student participants also SDM with a client. practiced using this tool An observer can throughout the role play also use this tool to activity. Student score someone else participants then used this tool to score their peer's ability to implement SDM during their educational classroom experience Customizable Included atools for decision-aid implementation section template a within the training to practitioner can use introduce this tool. For the with their client to IOTA presentation, filled out a sample decision SHARED DECISION MAKING TRAINING EVALUATION 63 better engage in the SDM process Specific Ottawa Decision Guides SDM Educational Handout Elwyns Three Step Model for SDM Handout Case Study Scenarios SDM Role Play Handout https://decisionaid.ohri.ca/AZlis Alphabetical list of t.html decision aids for various health topics that practitioners can use to better engage in the SDM process with their clients Product developed for training General information program on SDM, instructions for student assignment, how to evaluate students using Option Scale Product developed for training Visual representation program of Elwyns three step model for SDM Product developed for training program Product developed for training program Three case scenario descriptions with three treatment options for participants to read and reason through Instructions on the role play exercise for the students guide for the practice scenario demonstration and presented this to the participants Included a tools for implementation section within the training to introduce this tool Provided this handout to the professor of the MOT 505: Wellness in Occupation course to assist with her understanding of the student assignment associated with the training Provided this as an additional resource to supplement the presentation slides on Elwyns three steps. Included these in the role play section of the student presentation Instructed students to refer to this resource before completing the role play activity Table 2 Kirkpatrick Levels Timing of Evaluation Methods Kirkpatrick Level Evaluation Method Timeline of Use SHARED DECISION MAKING TRAINING EVALUATION 64 Baseline Measurement True/False SDM Knowledge & Attitudes Survey (Forcino et al., 2018) Completed prior to training. Blended Level 1 Reaction Evaluation & Level 2 Learning Evaluation Kirkpatrick Blended evaluation Plan Form, Pages 1 & 2 (Kirkpatrick & Kirkpatrick, 2016) Followed the completion of training. Occurred at the same time as the other Level 2 Evaluation below. Level 2-Learning Evaluation True/False SDM Knowledge & Attitudes Survey (Forcino et al., 2018) Followed the completion of training. Occurred at the same time as the Blended Level 1 & 2 Evaluation. Level 3-Behavior Evaluation Kirkpatrick Delayed Post-Training Survey (Kirkpatrick & Kirkpatrick, 2016) Completion of the Kirkpatrick Delayed Post-Training Survey occurred by the end of Spring semester 2022 for MOT students. Completion of both the OPTION scale and the Post-training survey occurred during the same time period. SHARED DECISION MAKING TRAINING EVALUATION Level 4-Results Evaluation 65 OPTION Scale-Five Item Version (Elwyn et al., 2013) We used the OPTION scale in two places during the study. Participants completed the OPTION scale during the role play section of the SDM training when they were an observer of the other students doing the role play. We did not utilize the tool to collect data. The purpose was to practice using the tool so the student could score their classmate on their use of SDM following the intervention session with the client volunteer. Second, the participants completed the OPTION scale for a Level 3 program evaluation following implementation of SDM with the client volunteers. Modified SDM Survey (Hrter & Scholl, 2018; Moyers et al. 2021) Following the intervention session with the client volunteer, students filled out the Modified SDM survey (Hrter & Scholl, 2018; Moyers et al. 2021). Table 3 Types of Training Outcomes Determining Program Effectiveness Criterion One: Kirkpatrick Levels One & Two General Outcomes of Training Measurement Criterion for determining program effectiveness Outcome SHARED DECISION MAKING TRAINING EVALUATION 66 The learner demonstrated improved knowledge of shared decision making. Compared knowledge scores from baseline to post-workshop survey or Level 2 evaluation. We graded the knowledge portion of the survey for correctness, and the students received a percentage of correct responses out of the items completed with a true/false response. Learners received a significantly higher knowledge score on the postworkshop SDM Knowledge and Attitudes Survey (Forcino et al., 2018) when compared to the baseline knowledge score. Achieved The MOT/MSW/ IOTA postworkshop scores were significantly higher than the preworkshop scores. The learner described attitudes supportive of shared decision making by the end of the training. Throughout the training, participants demonstrated improvement in attitude skills or Level 2 evaluation from baseline to level two pre and posttest survey. The attitude raw score had a maximum of 40. Learners received a significantly higher attitude score on the postworkshop SDM Knowledge and Attitudes Survey (Forcino et al., 2018) when compared to the baseline attitude score. Achieved There was a significant difference in pretraining and posttraining attitudes. Learners rated their confidence as 8 or higher on a 10-point Likert scale for the item: How confident are you that you will be able to apply what you have learned back on the job? Achieved The average response to the confidence question was an 8.24. The learner Level 1 posttest survey reported confidence of the Kirkpatrick regarding ability to Blended evaluation apply learning to approach clients at the (Kirkpatrick & assigned fieldwork Kirkpatrick, 2016). site. SHARED DECISION MAKING TRAINING EVALUATION The learner reported commitment to apply learning to clients at the assigned fieldwork site. Level 1 posttest survey or the Kirkpatrick Blended evaluation approach (Kirkpatrick & Kirkpatrick, 2016). Learners rated their commitment as 8 or higher on a 10-point Likert scale for the item: How committed are you to applying what you learned to your work? 67 Achieved The average response to the commitment question was 8.33. Criterion Two: Kirkpatrick Level 3 Behavior Change Outcomes Measurement Criterion for determining program effectiveness Outcome The learner reported clear understanding of expectations for application of SDM while on fieldwork. Level 3 Kirkpatrick (2016) Delayed Post-Training Survey. Learners rated their understanding at a 3 or 4 on a 4-point Likert scale for the item: I was clear about what was expected of me after taking the course. Achieved The average response to the expectation question was 3.14. The learner reported successfully applying learning about SDM to the fieldwork site. Level 3 Kirkpatrick (2016) Delayed Post-Training Survey. Learners rated their success in application of learning at a 3 or 4 on a 4-point Likert scale for the item: I am successfully applying what I learned in the course Achieved The average response to the application of the SDM question was 3.67. SHARED DECISION MAKING TRAINING EVALUATION The learner provided a specific example of how the course helped them achieve positive results when using SDM. Level 3 Kirkpatrick Delayed PostTraining Survey (2016). 80% of the learners provided an example of a learning application in response to the item: Please provide a specific example of how the course has helped you achieve positive results in your area. 68 Not Met Due to a lack of question response, 80% of learners did not provide an example of how they applied SDM in a learning environment. Criterion Three: Kirkpatrick Level 4 Training Program Impact Outcomes Measurement Criterion for determining program effectiveness Outcomes The learner successfully used the steps for shared decision making with at least one client while on fieldwork. Level 4. We summed each of the five items from the OPTION scale, ranging from zero to four (Elwyn et al., 2013), for a potential total raw score of zero up to 20 (Elwyn et al.). We rescaled the raw score on a scale of zero to 100. 80% of the learners scored 80 or better on the OPTION scale (Elwyn et al., 2013). Not Met Of the participants that completed the OPTION scale, 70 percent scored 80 or better. The learner described knowledge of shared decision making. Level 4. Modified SDM Survey (Hrter & Scholl, 2018; Moyers et al. 2021). 80% of the learners scored 710 on the Modified SDM Survey (Hrter & Scholl, 2018; Moyers et al. Not Met Of the participants that completed the survey, 71 percent scored 7 or higher. SHARED DECISION MAKING TRAINING EVALUATION 69 2021) knowledge question. The learner acknowledged client decision making as important to clientcentered practice. Level 4. Modified SDM Survey (Hrter & Scholl, 2018; Moyers et al. 2021). 80% of the learners selected items 3 through 5, which are the collaborative indicators, on the Control Preference Scale of the Modified SDM Survey (Hrter & Scholl, 2018; Moyers et al. 2021). Achieved 85 percent of the participants who completed the survey selected items 3 through 5. Table 4 Pre- and Post- Knowledge Descriptives MSW/MOT vs. IOTA Participants 95% Confidence Interval Group PreKnowledge 1 Mean 4.88 Lower Bound 3.74 Upper Bound 6.01 St Deviation 1.356 SHARED DECISION MAKING TRAINING EVALUATION PostKnowledge 70 2 5.21 4.17 6.26 1.805 1 6.75 5.78 7.72 1.165 2 6.50 5.91 7.09 1.019 Notes: include group categories and numbers* MSW.MOT = 1 IOTA = 2 Table 5 Pre- and Post- Attitude Descriptives MSW/MOT vs. IOTA Participants 95% Confidence Interval Overall attitude with seven or more variables Pre- Attitudes Post- Attitudes Group Mean St Deviation Lower Bound Upper Bound 1 1.990 0.2529 1.796 2.185 2 1.893 0.3453 1.702 2.085 1 2.203 0.1660 2.075 2.330 2 2.080 1.885 2.276 Notes: include group categories and numbers* MSW.MOT = 1 IOTA = 2 SHARED DECISION MAKING TRAINING EVALUATION 71 Table 6 Positive Evidence on the Kirkpatrick Blended Evaluation Open Ended Responses from Participants Participant Group Positive Evidence Theme IOTA Providing evidence-based options in combination with the patients preferences and abilities Evidence-based practice IOTA Using Ottawa will be beneficial for clients struggling with making decisions based on communication alone Acknowledging the resources MSW/MOT The resources provided, like the Ottawa, OPTION scale, and pocket card will likely all be helpful Acknowledging the resources MSW/MOT Mentors and supervisors may not be familiar with SDM, so some sort of training for them as well Training for supervisors SHARED DECISION MAKING TRAINING EVALUATION MSW/MOT Help to build rapport with my client(s) and ultimately help their conditions improve as well as their perception of their occupational performance 72 Improving client outcomes Note. These responses came from items 8, 9, 10A, 11, 12, & 13 on the Kirkpatrick Blended Evaluation Form. Table 7 Post Kirkpartick Blended Evaluation Descriptives IOTA/MOT Participants Questions Numbers Descriptives 95% Confidence Interval Mean St Deviation Lower Bound Upper Bound Q1 The class environment helped me to learn. 8.48 1.470 7.81 9.15 Q2 I was engaged with what was going on during the program. 8.62 1.117 8.11 9.13 Q3 The activities and exercises aided in my learning. 8.81 1.167 8.28 9.34 Q4 I was given adequate opportunity to practice what I was learning. 8.17 1.189 8.17 9.26 Q5 I will be able to immediately use what I learned. 8.52 1.750 7.73 9.32 Q6 The program material will 8.52 1.261 8.52 9.67 SHARED DECISION MAKING TRAINING EVALUATION 73 contribute to my future success. Q7 I would recommend this program to my coworkers or classmates. 9.14 0.727 8.81 9.47 Q10 How confident are you that you will be able to apply what you have learned at your fieldwork? 8.24 1.261 7.66 8.81 Q11 How committed are you to applying what you learned to your fieldwork? 8.33 2.153 7.35 9.31 Note. *We received permission to use and adapt the instrument for occupational therapy. Table 8 Modified SDM Survey Data Consultation Information Health Complaint/Problem/Illness Decision Made Spinal Cord Injury, Areas of Wellness Addressed emotional & spiritual wellness through yoga & journaling Stroke Focused on physical and emotional wellness Spiritual Wellness Client left decision up to therapist, did not wish to make decisions regarding intervention session Health & Wellness Client chose the order of the session SHARED DECISION MAKING TRAINING EVALUATION 74 T9 Incomplete Spinal Cord Injury Client desired to participate in all intervention options, so he prioritized them and chose the order of completion Physical & Emotional Wellness Client made intervention choices based on what he would likely do by himself Traumatic Brain Injury, Looking to Increase Social, Physical, and Intellectual Wellness Focus on social and physical wellness, seek out referral to recreational therapy, start journaling stories for his son with use of adapted apps. Table 9 Modified SDM Survey Descriptives Questions Numbers 95% Confidence Interval Descriptives Mean St Deviation Lower Bound Upper Bound Q1 How much do you know about the concept of shared decision making? 7.29 1.38 6.01 8.56 Q2 In your opinion, who should make the treatment decision? 3.29 0.951 2.41 4.17 Q5 I made clear to my patient that a decision needs to be made. 4.57 .787 3.84 5.30 Q6 I wanted to know exactly from my patient how they 4.43 .535 3.93 4.92 SHARED DECISION MAKING TRAINING EVALUATION 75 want to be involved in making the decision. Q7 I told my patient that there are different options for treating their medical condition. 4.86 .690 4.22 5.50 Q8 I precisely explained the advantages and disadvantages of the treatment options to my patient. 3.71 .756 3.02 4.41 Q9 I helped my patient understand all the information. 4.43 .535 3.93 4.93 Q10 I asked my patient which treatment option he/she prefers. 5.29 .756 4.59 5.98 Q11 My patient and I thoroughly weighed the different treatment options. 4.29 .951 3.41 5.17 Q12 My patient and I selected a treatment option together. 4.86 1.069 3.87 5.85 SHARED DECISION MAKING TRAINING EVALUATION Q13 My patient and I reached an agreement on how to proceed. 4.86 1.069 76 3.87 5.85 Note1. 1 is completely disagree and 6 is completely agree Note2. *We received permission to use and adapt the instrument for occupational therapy. Table 10 Quantitative Barriers from Modified SDM Survey Question Number Type of Barrier Mean Score St 95% Deviation Confidenc e Interval Highest Frequency of Responses Outcome 14 Lack of time hinders or hindered me to actively involve clients in decision making. 3.00 1.16 1.93-4.07 3- strongly disagree Some students found this to be a barrier. 17 Usually there is or was just one intervention option available and therefore there was no choice to actively involve clients in decision making. 2.43 1.27 1.25-3.61 2- completely disagree There was a larger range of frequencies due to the limited number of sessions the students had with the clients. Clients do or did not want to participate in decision making. 3.00 Clients have or had misconceptions about the disease or the intervention and therefore active involvement in 2.29 18 19 2- strongly disagree 2- somewhat agree 1.41 1.69-4.31 2- strongly disagree 2- somewhat agree .951 1.41-3.17 4- strongly disagree The students found some clients wanted to be a part of the decision making. The students did not believe the clients had misconceptions about the intervention. SHARED DECISION MAKING TRAINING EVALUATION 77 decision making was difficult. 20 21 I lack or lacked knowledge on how to actively involve clients in decision making. 2.71 It makes no sense to 1.57 actively involve clients in decision making. .756 2.02-3.41 3- strongly disagree 3- somewhat disagree .535 1.08-2.07 4- strongly disagree The students believed the training prepared them to engage in SDM with their clients. The students adamantly believed SDM was beneficial to the clients. Note. *We received permission to use and adapt the instrument for occupational therapy. SHARED DECISION MAKING TRAINING EVALUATION 78 Table 11 Delayed Post Kirkpatrick Evaluation Descriptives MOT Participants Questions 95% Confidence Interval Numbers Descriptives Mean St Deviation Lower Bound Upper Bound Q1 I was clear about the purpose of the training before I attended 3 0.577 2.47 3.53 Q2 I was clear about what was expected of me after the training 3.14 0.690 2.5 3.78 Q4 I am successfully applying what I learned in the training 3.67 1.464 1.79 4.50 Q7 The course was a worthwhile use of my time 3.71 1.254 1.55 3.87 Q8 I am already seeing positive results from this training 3.14 0.690 2.5 3.78 Q9 I am expecting positive results from this training in the future 3.29 0.488 2.83 3.74 Note: *We received permission to use and adapt the instrument for occupational therapy.  ...

... Title: Implementation of an Occupation-Based Screening Tool at Eskenazi Health- EMBRACE Program to Improve Occupational Therapy Referrals Taylor Henson April 22, 2022 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: DeAnna Wesley, EMBRACE Program Director Abstract There is currently no developed screening tool indicating occupational performance deficits and the need for referrals to OT in the cancer survivor population. This paper reviews the implementation of the SOCS-OTS at Eskenazi Health, which is a recently developed content valid, occupation-based screening tool. Researchers have shown the need for OT services in oncology. However, OT services are underutilized. I partnered with the EMBRACE program within Eskenazi Health and administered the SOCS-OTS to oncology patients to improve OT referrals. I tripled the amount of OT referrals and generated possible profits for the hospital through these referrals. I was also able to train social workers within the EMBRACE program on administering the SOCS-OTS so we can continue to improve referral rates. We, as healthcare professionals, must continue to advocate for OT services and OTs role in oncology care to enhance the quality of life for cancer survivors. Introduction Eskenazi Health is a level one trauma center located in downtown Indianapolis. This hospital is a 315-bed facility that is well known for its particular emphasis on vulnerable populations of Marion County. Within Eskenazi Health, a program called EMBRACE reaches out to newly diagnosed cancer patients, helping them through the emotions and confusion that come with a cancer diagnosis (Eskenazi Health, 2016). The EMBRACE team also provides encouragement and addresses many cancer survivors' concerns (Eskenazi Health, 2016). Three social workers make up the EMBRACE team that works closely with the oncologists, dieticians, nurses, and other healthcare professionals. The EMBRACE program has close ties with many community resources, such as Little Red Door and Meals on Wheels. The EMBRACE program also utilizes grants to help fund resources, such as Lyft, and provides vouchers for meals, transportation, and prescriptions. For my project, I will be screening cancer survivors in the oncology clinic alongside the social workers using the Screen of Cancer Survivorship - Occupational Therapy Services (SOCS-OTS). The SOCS-OTS is a recently developed content valid, occupation-based screening tool that can be used to improve occupational therapy (OT) referrals. Survivors experience many side effects of treatment that may impact occupational performance and overall quality of life (Brekke et al., 2019). OT practitioners are skilled in addressing these late side effects and occupational performance deficits for improved overall quality of life in cancer survivors. Although survivors face performance deficits resulting from cancer treatment, many physicians do not refer them to OT services. Pergolotti et al. (2014) found that only 32% of their total sample had a referral OT within the first two years of their cancer diagnosis. In this paper, I will further discuss how the implementation and training of staff on an occupation-based screening tool for cancer survivors support the mission of Eskenazi Health. Background As of 2016, researchers estimated that there were 15.5 million cancer survivors in the United States and that by the year 2026, that number will rise to 20.3 million (National Cancer Institute, 2018). Researchers define a cancer survivor as anyone with or who had cancer from diagnosis to the end of life (National Cancer Institute, 2019). As the number of cancer survivors increases, it is essential to consider what factors may impact their quality of life following cancer treatment. Researchers indicated that quality of life was inversely related to occupational performance deficits, which can occur due to side effects of cancer treatment such as fatigue, pain, sensory loss, and cognitive impairments (Brekke et al., 2019). Occupational performance is the accomplishment of an occupation which is a purposeful activity that has meaning to the individual (American Occupational Therapy Association, 2014). In 2006, the Institute of Medicine (IOM) called for the implementation of cancer survivorship recommendations and plans to improve care coordination and follow-up care and assure patient outcomes. The American Society of Clinical Oncology (ASCO) Survivorship Care Plan (SCP) is a document that includes a treatment summary and follow-up care plan to improve communication and coordination of care for cancer survivors. It helps patients track check-ups or follow-up tests, maps out possible late side effects of treatment, and provides ideas for staying healthy (Centers for Disease Control and Prevention, 2018). The ASCO SCP addresses concerns related to emotional and mental health, physical functioning, memory or concentration loss, fatigue, parenting, school/work, and sexual functioning. However, the SCP in care coordination does not include various life activities (occupations) that researchers found cancer survivorship impacts (American Society of Clinical Oncology, 2019). Researchers have recommended an occupational participation approach to cancer survivorship care to address gaps in care (Yim Loh & Jonsson, 2016). Side effects of cancer treatment impact every category of occupation, including ADLs (Activities of Daily Living), IADLs (Instrumental Activities of Daily Living), rest and sleep, work, leisure, and social participation (American Occupational Therapy Association, 2014). Although survivors face performance deficits, many do not receive referrals to OT services. After completing the needs assessment at my site, I found that the primary goal of the EMBRACE clinic is to remove barriers to care for cancer survivors, and often the most significant obstacle for the patients is transportation. I also found that Eskenazi Health does not provide cancer survivors with a SCP. Cancer survivors face a variety of physical and psychosocial deficits due to cancer treatment. However, many patients needs are not being taken care of because they are not getting OT referrals. There is no OT on staff in the outpatient oncology clinic, and many healthcare professionals working in this clinic do not know the role of OT in oncology care. Additionally, there are very few oncology referrals to outpatient OT. All of the information gained from the needs assessment confirmed that my project is necessary at this site to help cancer survivors improve their quality of life through an occupation-based screening to help them with their occupational performance deficits. Currently, there are no developed screening tools indicating the need for referral to OT in survivorship care. Therefore, researchers have not written on this specific topic. However, researchers have discussed the need for OT and advocacy for OT in oncology care. While many researchers have called out the need to advocate for the OT profession and our services, there is little evidence about the effectiveness of advocating for OT services. Some researchers have suggested that individuals advocate for more OT referrals by educating the multidisciplinary team on the unique skill set of the OT profession (Sleight & Duker, 2016). Researchers also believe that we may be successful in increasing the amount of OT referrals by educating other health professionals on the fact that OT does physical treatment and psychosocial (Sleight & Duker, 2016). My work differs from other research because not only will I be advocating for OT in oncology care, but I will also be implementing an occupation-based screening tool, which other researchers have not yet done. Models Used to Guide My Project One model I chose to guide my DCE is the Canadian Model of Occupational Performance (CMOP). I chose this because of its focus on the Person, Environment, and Occupation. I also chose this model because of its emphasis on the client's human spirit. The Person component is affected by cancer treatment because survivors face various physical and cognitive side effects, such as impaired memory, concentration, and energy (Hwang et al., 2015). The Occupation component is also affected by cancer treatment because it affects their ability to complete meaningful occupations, such as personal care, work, and socialization (Hwang et al., 2015). The Environment component is affected because this is where survivors perform their various occupations, and an environment can be beneficial or harmful to helping a survivor complete their occupations. The Environment component is also affected because I will be working in an outpatient clinic, and survivors now must learn to be independent again and manage their side effects (Cole & Tufano, 2008). Cancer survivors face various side effects before, after, and during cancer treatment, which affects the Person. Due to the Person being affected, that also affects Occupation and Environment. While completing my DCE project, it is essential to consider all parts of the cancer survivor. It is also vital that I determine the driving force for each survivor and keep that at the center of my focus. Another model I chose to guide my DCE is the Emergency Severity Index (ESI), a triage tool for emergency department care. Triage nurses use ESI to categorize patients into five different levels based on the patients condition. Nurses use level one for most urgent patients and use level five for patients that are least urgent (Adler et al., 2019). Researchers have found that this rapid sorting method can improve patients' flow through the emergency department (Adler et al., 2019). This model relates to my project specifically because I used a triage model when deciding which oncology patients to refer to outpatient OT services. After discussion with the outpatient rehabilitation manager, she reported that her staff already has a full caseload but would be willing to have me send the oncology patients to her that are most in need of OT services. Therefore, I used a triage-based system to determine which patients OT needs were most urgent and least urgent and sent a reasonable number of referrals to the outpatient rehabilitation team. Project Design After examining the literature and talking with stakeholders at my site, I realized the need to implement the SOCS-OTS to determine occupational performance deficits that cancer survivors face. I discussed the referral process with stakeholders and used a triage system to get referrals to outpatient rehabilitation services. Through discussion with stakeholders, we concluded that I would find the most vulnerable patients in need of OT and have the oncologist put in an order for an OT referral. Then, I would send a list of the patients' names to the outpatient rehabilitation manager to help set up appointments. I also briefly educated the outpatient physical therapist (PT) working with post-mastectomy patients on using the SOCSOTS to screen for OT services for those patients that have only been referred to PT. Lastly, I trained and educated social workers on the EMBRACE team on using the SOCS-OTS for sustained regular OT screening. Additionally, I created a VoiceThread of my educational training on the SOCS-OTS, in case there is turnover within the EMBRACE team. The outcome assessments that I have chosen are formative and summative evaluations. For the formative evaluation, I looked at the number of referrals for OT services before and after the implementation of SOCS-OTS. The formative evaluation also consisted of a pretest and posttest of the EMBRACE social workers knowledge on OT referrals before and after an educational training on the SOCS-OTS. The summative evaluation consisted of having the EMBRACE social workers give feedback on the educational training I have provided. Specifically, I asked if there are any improvements I can make to help deepen their understanding of the SOCS-OTS and OT referral process. Project Implementation Before implementing my project, I had to figure out how the referral process would work if a patient were to show the need for OT services. After talking with the outpatient rehabilitation manager, there was some pushback from her about sending her referrals. She reported that this was because the therapists already have a substantial caseload. It was initially a challenge to get this stakeholder on board. However, after a meeting with her, my site mentor, and my faculty mentor, we were able to develop the solution of using a triage approach. By having this meeting, we were able to get everyone on the same page. In this meeting, my faculty mentor and I were further able to discuss the creation of the screening tool, OTs role in oncology, and the need for increased OT referrals for oncology patients. After this discussion and getting a better understanding of my project, the outpatient rehabilitation manager was willing to help get oncology patients in for an OT evaluation. I then began screening oncology patients using the SOCS-OTS and triaging which patients were most in need of OT services. See Appendix A for SOCS-OTS questionnaire. After triaging, I requested a referral for outpatient OT services from the patient's oncologist via an in-basket message on EPIC. I initially thought it would take the oncologist a while to put the referral in or felt that they would question my judgment. However, they were quick and agreeable to put the referral in, which helped the success of my project. Then, I would send the patient's name to the outpatient rehabilitation manager via an in-basket message and she would reach out to the patient to schedule appointments. Additionally, I created an educational training PowerPoint on what OT is, OTs role in oncology, and how to administer the SOCS-OTS for the EMBRACE team. Then I made a VoiceThread with this PowerPoint due to having difficulties getting all EMBRACE team members in the same place at the same time. It was also beneficial to create this VoiceThread for the EMBRACE team if there was any staff turnover and to support the sustainability of this referral program. In this case, the new staff members would also be able to watch this presentation and better understand OTs role and how to administer the screening tool. Before sending out the VoiceThread, I sent out a pre-test for the EMBRACE team to complete and then sent out the post-test for them to complete after watching the presentation. Project Outcomes The assessment tool I used for my project was the Screen of Cancer Survivorship Occupational Therapy Services (SOCS-OTS). I chose to use this recently developed occupationbased screening tool because I realized that there were oncology patients with occupational performance deficits after completing the needs assessment. However, nobody talked to them about these deficits, and they were not getting OT referrals for their occupational performance needs. Before implementing an OT referral program, over a 60-day period there were only two referrals to outpatient OT services for oncology patients. After implementing the OT referral program by using the SOCS-OTS, I was able to screen 50 oncology patients in 45 days and obtain six referrals to outpatient occupational therapy services. By implementing the SOCSOTS, I was able to generate a 200% increase in referrals. See Table 1 for data. In a shorter time, I was able to triple the number of referrals for occupational therapy. Table 1 Screening Period Dates: Screening Period Number of Days: Number of Individuals Screened: Number of OT Referrals: 12/2/20211/31/20222 60 N/A 2 1/31/20223/18/2022 45 50 6 As I was implementing the SOCS-OTS, I looked into the most common payer sources at Eskenazi Health. I found that 25% of patients at this site have Medicaid, 26% have Medicare, 20% have Healthy Indiana Plan (HIP), 12% have Health Advantage/Self-Pay, 14% have commercial insurance, and 3% have other. Along with payer sources, I also discussed the profits generated from OT evaluations with the outpatient rehabilitation manager. The hospital profits $170.00 for Medicaid evaluations, $96.00 for Medicare evaluations, $0.00 for Health Advantage evaluations, and $102.00 for evaluations for those that are employed by Eskenazi that need therapy. See Table 3 for the breakdown of profits generated from the six referrals for OT services that I obtained. When totaling the possible profits generated from the six referrals, I found that it would be $804.00. Table 3 Patient: Patients Pay Source: Possible Profit from OT Evaluation: Patient 1 MDWISE HIP $170.00 Patient 2 UNITED HEALTHCARE MEDICARE $96.00 Patient 3 ANTHEM HIP $170.00 Patient 4 AETNA MEDICARE $96.00 Patient 5 ANTHEM HIP $170.00 Patient 6 UMR H&H EMPLOYEE $102.00 At this rate, there could be 400 oncology patients screened per year and 48 referrals to OT services. Additionally, at this rate, the hospital could profit ~$6,500 per year from these referrals if the patients participate in the OT evaluation. For my outcome measurements, I used pre and post-test results. I created a questionnaire on Google Forms consisting of four questions and had the three social workers within the EMBRACE program fill them out before completing educational training. The possible choices on the Likert scale that the social workers could choose for each statement on the survey were: Strongly Disagree, Disagree, Neutral, Agree, and Strongly Agree. See Appendix B for pre-test data. See Table 4 below for pre and post-test results from the questionnaire. Next, I created a PowerPoint educating the EMBRACE team on what OT is, OTs role in oncology, and how to administer the SOCS-OTS. I then made this PowerPoint into a VoiceThread due to having difficulties getting all of the staff in the same place at the same time. I then sent out the VoiceThread presentation and the post-test survey, which had the same questions as the pre-test, along with one comment box asking for feedback on the training and if there are any improvements they would like to see on the training. See Appendix C for post-test data. See Table 4 below for pre and post-test date from the questionnaire. Table 4 Statement Average Percentage of EMBRACE Team that Strongly Agree (Pre-Test) 33.3% Average Percentage of EMBRACE Team that Strongly Agree (Post-Test) 100% I understand the role of OT in oncology 66.7% 100% I understand how to administer the Screen of Cancer Survivorship Occupational Therapy Services (SOCS-OTS) 33.3% 100% I understand how to get a referral for OT services 66.7% 100% I have a good understanding of the OT profession The comment box for the post-test asked, What are your thoughts on the training that was completed? Are there any improvements that could be made to the training to help deepen your understanding of the SOCS-OTS? All members of the EMBRACE team indicated that the training program was overall successful. The first comment stated, Training was well done and easily understood. The second comment said, Very well done! The third comment stated, The training was terrific! It was clear, thorough, comprehensive, and easy to follow, especially for those with an OT background. I am so grateful for the information and am committed to continuing our dedicated efforts to regularly screen our oncology patients and incorporate OT as part of their treatment journey through survivorship care. THANK YOU! Summary For my project, I completed a needs assessment to guide my project, implemented the SOCS-OTS, discontinued the screening process, and worked on the sustainability of the use of the SOCS-OTS once I was no longer on site. For the needs assessment, I discussed the needs of the hospital and the EMBRACE program with the EMBRACE program director and the social workers who work within the EMBRACE program. I also talked with cancer survivors and discussed their needs and the issues they were facing. Next, I discussed the referral process with the outpatient rehabilitation manager if there were to be patients that showed the need for OT services using the SOCS-OTS. After figuring out that a triage approach would work best, I began to screen cancer survivors using the SOCSOTS. I screened 50 patients in 45 days and obtained six referrals for outpatient OT services. This number of referrals tripled the number of referrals in 60 days before implementing the SOCSOTS. Also, I talked with the outpatient rehabilitation manager about the profits generated from referrals. I calculated that there was the potential for $804.00 generated from the six referrals if all of the patients participated in the OT evaluation. At this rate of screening patients, there could be 400 patients screened in one year. Additionally, at this rate of patient referrals, 48 patients could be referred to OT services in one year, bringing in ~$6,500 in profits. Lastly, I created an educational training PowerPoint and VoiceThread for the EMBRACE social workers to view. This educational training presentation allowed the social workers to improve their knowledge of OT, OTs role in oncology, and how to administer the SOCS-OTS. Before the social workers viewed this training, I sent out a pre-test to assess their knowledge of these components before viewing the training. After they watched the training, I then sent out a post-test with the same questions with the addition of a comment box for feedback if there were any additional questions or information needed in this training. While looking at the differences in responses from the pre and post-test, I was able to see that all three social workers knowledge improved due to the educational training. By giving this training, the social workers will now be able to successfully administer the SOCS-OTS once I have left the site. Conclusion Over the past 14 weeks, I have learned and accomplished quite a few things. See Appendix D for weekly log of objective and tasks completed. I improved my interpersonal communication, advocacy, and time management skills, just to name a few. I worked closely with the EMBRACE team, which allowed me to understand the social work profession more clearly. I also was able to see the side effects of treatment and deficits that cancer survivors are facing firsthand. With the implementation of the SOCS-OTS, I was also able to obtain six referrals to outpatient OT services in 45 days, compared to the two referrals obtained in 60 days before the implementation of the SOCS-OTS. Additionally, with the referrals obtained, I doubled the possible profits generated from OT evaluations in the outpatient clinic. Eskenazi Health, the EMBRACE program, and cancer survivors benefitted from this project. The cancer survivors treated at Eskenazi demonstrated potential for improved quality of life due to improved referrals to OT services. The hospital benefitted from improved OT referrals due to the improved potential profits generated from these referrals. Additionally, the EMBRACE program benefitted from this project because the social workers are now more knowledgeable about OT, OTs role in oncology care, and how to administer the SOCS-OTS. With the social workers trained to administer the SOCS-OTS, their program can also provide more holistic services to their patients. Practitioners in oncology care can use the SOCS-OTS tool to identify activities that the client cannot perform to their satisfaction. OT practitioners, in particular, must continue to advocate for the OT profession and OTs role in oncology care. OT practitioners must also continue to talk with their oncology patients about how they are doing and if they have trouble with their daily activities. Otherwise, there might not be anybody else talking to them about these activities. Further work may need to be done on the SOCS-OTS to refine items or wording for particular items. Overall, OT practitioners must continue to advocate for the OT profession and their role in oncology care, as we can treat cancer survivors physical and psychosocial needs, leading to improved quality of life. References: Adler, D., Abar, B., Durham, D. D., Bastani, A., Bernstein, S. L., Baugh, C. W., Bischof, J. J., Coyne, C. J., Grudzen, C. R., Henning, D. J., Hudson, M. F., Klotz, A., Lyman, G. H., Madsen, T. E., Pallin, D. J., Reyes-Gibby, C. C., Rico, J. F., Ryan, R. J., Shapiro, N. I., Swor, R., Caterino, J. M. (2019). Validation of the Emergency Severity Index (Version 4) for the triage of adult emergency department patients with active cancer. The Journal of Emergency Medicine, 57(3), 354361. https://doi.org/10.1016/j.jemermed.2019.05.023 American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1-S48a American Society of Clinical Oncology. (2019). Survivorship care planning tools. https://www.asco.org/practice-guidelines/cancer-care-initiatives/preventionsurvivorship/survivorship-compendium Barton, M. (2014). Oncologists and primary care physicians infrequently provide survivorship care plans. Ca: A Cancer Journal for Clinicians, 64(5), 291-292. doi:10.3322/caac.21240 Brekke, M. F., la Cour, K., Brandt, A., Peoples, H., & Waehrens, E. E. (2019). The association between ADL ability and quality of life among people with advanced cancer. Occupational Therapy International, 1-10. doi:10.1155/2019/2629673 Centers for Disease Control and Prevention. (2018, April 19). Survivorship care plans. https://www.cdc.gov/cancer/survivors/life-after-cancer/survivorship-care-plans.htm Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, N.J.: SLACK Inc. Eskenazi Health. (2016). About. https://www.eskenazihealth.edu/about Eskenazi Health. (2016). EMBRACE. https://www.eskenazihealth.edu/programs/embrace Hwang, E. J., Lokietz, N. C., Lozano, R. L., & Parke, M. A. (2015). Functional deficits and quality of life among cancer survivors: Implications for occupational therapy in cancer survivorship care. The American Journal of Occupational Therapy, 69(6). doi:10.5014/ajot.2015.015974 National Cancer Institute. (2019). NCI dictionary of cancer terms: Survivor. Retrieved from https://www.cancer.gov/publications/dictionaries/cancer-terms/def/survivor National Cancer Institute. (2018). Cancer statistics. Retrieved from https://www.cancer.gov/about-cancer/understanding/statistics Pergolotti, M., Bailliard, A., McCarthy, L., Farley, E., Covington, K.R., & Doll, K.M. (2020). Women's experiences after ovarian cancer surgery: Distress, uncertainty, and the need for occupational therapy. The American Journal of Occupational Therapy, 74(3). https://doi.org/10.5014/ajot.2020.036897 Sleight, A. G., & Duker, L. I. S. (2016). Toward a broader role for occupational therapy in supportive oncology care. American Journal of Occupational Therapy, 70(4), 70043600301. https://doi.org/10.5014/ajot.2016.018101 Yim Loh, S., & Jonsson, H. (2016). Cancer survivorship care: A perspective from an occupational-participation approach. Journal of Cancer Science & Therapy, 8(7), 179-184. Appendix A Screen of Cancer Survivorship Occupational Therapy Services (SOCS-OTS) Instructions: Please check all items that you would like assistance with improving. Item Activities of Daily Living (ADL) Bathe and/or shower Engage in sexual activity and/or sexual expression (e.g., hugging, kissing, foreplay, masturbation, oral sex, intercourse) Engage in activities to give and receive affection needed to successfully interact in close personal relationships (e.g., friends, family members, intimate partners) Move self from one position or place to another (e.g., reaching, moving in bed, moving in wheelchair, performing transfers, walking during tasks and transporting items) Toilet and toilet hygiene Dress/undress (e.g., fasten and adjust clothing and shoes, remove personal devices/prosthetic devices/splints) Personal hygiene and grooming (e.g., using a razor, applying cosmetics, combing or brushing hair, caring for nails, applying deodorant, brushing/flossing teeth, denture care) Instrumental Activities of Daily Living (IADL) Provide care for others (e.g., childcare, caring for older parents, etc.) Drive and move around the community (e.g., using public or private transportation) Manage finances Clean my home Plan, prepare, serve and/or clean up meals Grocery shop (e.g., prepare grocery list, order online/go to store, bag groceries, unloading groceries, paying) [modified item Health Management Maintain my desired exercise routine and physical fitness Manage my medications (e.g. filling prescriptions at the pharmacy, understanding medication instruction, taking medications on a routine basis, refilling prescriptions in a timely manner) Manage my health (e.g., communicate with healthcare providers, understand recommendations for care plan, manage symptoms and conditions, etc.) Rest and Sleep Rest and sleep Work Engage in desired work performance and/or returning to work Leisure Participate in leisure activities Social Participation Socialize with my family and friends Please check all that apply This document is currently undergoing the copyright process. This document is being used with permission by Katie Polo at the University of Indianapolis. Please contact Katie Polo at polok@uindy.edu with any questions. Appendix B Pre-Test Results: Appendix C Post-Test Results: Appendix D Doctoral Capstone Experience and Project Weekly Planning Guide Week 1 DCE Stage (orientation, screening/evaluation, implementation, discontinuation, dissemination) Orientation Weekly Goal 1) Complete orientation by the end of the week Objectives Meet with site student coordinator, site mentor, other site personnel, and the site participants to introduce myself and educate them on why I am here Understand site environment/where my work area is/dress code/ etc. Tasks Ensure that all paperwork for orientation is complete Weekly staff meeting via phone call on Wednesday from 2-3 pm Set up recurring meeting with faculty mentor Date complete 1/11 1/12 1/24 1/10 1/12 Screening/Evaluation Begin to review literature 2)Continue to work on Needs assessment Finalize questions for Needs Assessment 1/19 Determine who to meet with and what questions to ask Set up meetings with key personnel (outpatient therapy manager, site mentor, social workers) 2 Screening/Evaluation 1)Begin to look at literature for outcome measure 2)Complete Needs assessment by end of the day Tuesday Establish outcome assessment Review outcome assessments with site mentor & faculty mentor Weekly staff meeting via phone call on Wednesday from 2-3 pm Talk with patients to better understand the 1/14, 1/24 1/19 1/20 1/21 needs of cancer survivors Meet with outpatient OT manager 3 Screening/Evaluation 1)Determine referral process Establish outcome measure Work on introduction section of scholar report Group meeting with outpatient OT manager, faculty mentor, and site mentor Weekly staff meeting via phone call on Wednesday from 2-3 pm Exploring literature on most common occupational performance deficits for patients with breast cancer, as well as cancer in general 1/28 1/26 1/28 1/28 Finish introduction section of scholar report 4 Implementation 1)Begin to screen patients using the SOCS-OTS Screen 3 people/day Work on background draft for scholar report Meeting with faculty mentor Weekly staff meeting via phone call on Wednesday from 2-3 pm Discuss grants with site mentor, DeAnna Review literature on summative evaluation (outcome measure) 2/1 2/2 2/2 2/4 2/5 5 Implementation 1)Continue screening patients using SOCS-OTS Screen 3 people/day Work on project design section for scholar report Finish background draft for scholar report Weekly staff meeting via phone call on Wednesday from 2-3 pm Roundtable meeting with Eskenazi Therapy Manager 2/9 2/11 2/11 Finish project design section for scholar report 6 Implementation 1)Continue screening patients using SOCS-OTS Screen 3 people/day Weekly staff meeting via phone call on Wednesday from 2-3 pm 2/16 2/17 Checking in with outpatient therapy manager 7 Implementation 1)Continue screening patients using SOCS-OTS Screen 4 people/day Weekly staff meeting via phone call on Thursday from 1-2 pm 2/24 2/25 Review literature for triage approach model/FOR 8 Implementation 1)Continue screening patients using SOCS-OTS Screen 4 people/day Weekly staff meeting via phone call on Thursday from 1-2 pm Review literature for triage approach model/FOR 3/3 3/4 3/4 Work on Model section of scholar report 9 Implementation 1)Continue screening Screen 4 people/day Meeting with faculty mentor 3/7 3/7 patients using SOCS-OTS Clarification of timeline for DCE Review literature for triage approach model/FOR Clarification of dissemination for DCE Meeting with site mentor Clarification of outcome assessment details Checking in with outpatient therapy manager Weekly staff meeting via phone call on Thursday from 1-2 pm 3/7 3/8 3/10 3/11 Work on Model section of scholar report 10 Implementation 1)Continue screening patients using SOCS-OTS Screen 4 people/day 3/15 staff on SOCS-OTS 3/17 Calling patients to check in and see if anyone had reached Work on educational training out to them about PPT for EMBRACE scheduling an OT appointment Gather materials to make folder for EMBRACE staff 11 Discontinuation/Wrapping Up Work on project outcomes for scholar report Set-up dates/times for discussions and presentations Finish pre/post-test surveys and clarify with faculty mentor Finish educational training PPT Weekly staff meeting via phone call on Thursday from 1-2 pm Finish up parts of project outcomes that I can complete Creating pre/post-test surveys on Google Forms Send out pre-test survey to EMBRACE staff Weekly staff meeting via phone call on Thursday from 1-2 pm 3/18 3/22 3/23 3/24 3/24 Set up meeting with outpatient PT (working with oncology patients) to briefly discuss SOCS-OTS Finish educational training PPT for staff on OT and SOCSOTS 3/24 3/25 3/25 Make VoiceThread for educational training PPT for EMBRACE staff Meeting with faculty mentor about SOCSOTS 12 Discontinuation/Wrapping Up Finish as much as possible for dissemination PPT (waiting on post-test results) Work on scholar report Send out VoiceThread to EMBRACE staff Send out post-test survey to EMBRACE staff Brief discussion with outpatient PT (working with oncology patients) to briefly discuss SOCS-OTS at 10 am Weekly staff meeting via phone call on Thursday from 1-2 pm 3/28 3/28 3/31 3/31 4/1 Work on Outcomes, Abstract, Summary, and Conclusion for scholar report 13 Dissemination/Wrapping Up Get post-test results from EMBRACE staff Get final outcome measure from EMBRACE staff 4/4 4/6 Disseminate project to EMBRACE staff Disseminate project to outpatient rehabilitation manager Work on scholar report Dissemination to outpatient rehab manager Weekly staff meeting via phone call on Thursday from 1-2 pm Meeting with EMBRACE staff and LRD to discuss transportation issues Dissemination to EMBRACE staff from 3-3:30 pm 4/7 4/7 4/7 4/7 Finish up Outcome section of scholar report Finish up Abstract, Summary, and Conclusion for scholar report 14 Wrapping Up Work on UIndy DCE PPT Presentation Finish up UIndy DCE PPT Presentation Work on UIndy DCE Poster Finish up UIndy DCE Poster Work on UIndy DCE VoiceThread Finish up UIndy DCE VoiceThread Complete faculty mentor/student final evaluations Finish up faculty mentor/student final evaluations Weekly staff meeting via phone call on Thursday from 1-2 pm 4/11 4/13 4/14 4/14 4/14  ...