搜

... AN EDUCATIONAL SERIES ON SYMPTOM MANAGEMENT 1 Enhancing Empowerment within Cancer Survivorship: A Symptom Management Program Darby Wildschuetz, OTS May 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Katie Polo, DHS, OTR, CLT-LANA AN EDUCATIONAL SERIES ON SYMPTOM MANAGEMENT 2 Abstract The cancer population is a growing number as treatment evolves and advances. More individuals are facing the harsh side effects that come with such advances during treatment and years after (American Cancer Society, 2023). Many patients are also not aware of these side effects that can occur or how to manage them for maintaining their quality of life (Sae'd Abu ElKass et al., 2021). The purpose of this program was to develop a series of educational workshops addressing the commonly reported symptoms members at the Cancer Support Community of St. Louis experience: cancer-related fatigue, cancer-related cognitive impairments, and cancerrelated peripheral neuropathy. Data was collected through self-reported pre and post surveys to assess their understanding of the symptoms associated with the side effect and how to implement management strategies. The main findings indicated positive results, supporting educational workshops as an effective method on improving understanding of symptoms and management strategies within cancer survivorship for improved quality of life. Keywords: side effects, symptoms, cancer, fatigue, peripheral-neuropathy, cognition AN EDUCATIONAL SERIES ON SYMPTOM MANAGEMENT 3 Introduction Cancer survivorship can be defined as anyone diagnosed with cancer in any stage of the disease such as onset and active treatment or remission (Cancer.Net, 2022). Those in cancer survivorship experience many different symptoms and side effects throughout their cancer continuum. Many do not realize what these side effects are and how to best manage them. Ketterl et al. (2019) surveyed 872 cancer survivors on the effects of cancer treatment on their daily functions. The authors found that 76.3% of survivors felt that the lasting effects of cancer limited the type and duration of their instrumental activities of daily living. The most commonly unmet needs amongst this population included emotional support, fatigue, and being informed about benefits and side-effects of treatment (Wang et al., 2018). It is critical to identify these needs in order to provide the best client-centered care for prevention and management. Community centers like the Cancer Support Community of St. Louis (CSC) are working to fill this gap in cancer care. CSC is a nonprofit organization that serves those impacted by cancer in the Greater St. Louis area. Their members include friends and family of the individual facing cancer, those grieving the loss of a loved one to cancer, and those in cancer survivorship. The site offers various programs to this population such as support groups, counseling, art therapy, movement classes, and educational workshops. Targeting these symptoms and addressing the unmet needs these cancer survivors face through educational workshops could increase their awareness, self-management of symptoms, and overall quality of life. The primary aim of this project is to measure the effectiveness of an educational series through the lens of occupational therapy on learning about the symptoms and implementing coping strategies in order to increase participation/performance with daily tasks. AN EDUCATIONAL SERIES ON SYMPTOM MANAGEMENT 4 Background More than 18 million individuals had a history of a cancer diagnosis in January 2022 according to the American Cancer Society. Over 1.9 million new cancer diagnoses are expected to occur in 2023 (American Cancer Society, 2023). With cancer cases rising, more and more individuals are facing the challenges that come with it and its treatment (What is cancer?, n.d.). The treatment for cancer includes surgery, chemotherapy, radiation, stem cell or bone marrow transplant, targeted therapy, or hormone therapy. Not only do cancer patients face symptoms from their disease, but they also face side effects from their treatment. Drott et al. (2022) examined the impact of symptoms on daily life and health of cancer patients and found that the uncertainty of the cancer experience played a large role in increased psychological distress and reduced quality of life. Rohilla et al. (2022) and Yale Medicine (2022) reported some of the most common side effects include pain, fatigue, anemia, hair loss, mouth problems, and nausea/vomiting. These effects may linger and cause long term effects on their participation in daily tasks (Faaij et al., 2022). Efverman (2023) completed a study on reported activity levels at baseline, during radiotherapy, and a month after. This author found that patients' physical, leisure, social, housework, and shopping activity levels decreased during radiotherapy and almost half of the patients activity levels were not restored a month after radiotherapy. Additionally, the author found that those whose prior activity levels did not return were also more likely to experience an anxious and depressed mood and a poor quality of life. A study by Sae'd Abu El-Kass et al. (2021) had similar findings and were most affected with instrumental activities like money management, shopping, housecleaning, and meal preparation. The authors also reported, More than half of the studied patients, 55.3%, had poor knowledge about cancer, side effects of chemotherapy, how to manage these side effects, and level of self-care efficacy. AN EDUCATIONAL SERIES ON SYMPTOM MANAGEMENT 5 The authors continued to state throughout their article that many hospital staffing were too busy and overcrowded to properly educate these patients. Van Dyk & Ganz (2021) found that many women with breast cancer were not aware of the cognitive decline that could occur post treatment. In addition, they stated the National Comprehensive Cancer Network guidelines recommend increasing education on cognitive impairments as being important for this population. Henderson et al. (2019) found similar findings and that most women commonly discovered cognitive impairments through fellow survivors by word of mouth. Additionally, Savina & Zaydiner (2019) explored cancer-related fatigue and reported that, Many patients with fatigue do not discuss treatment options for this disorder with their oncologists; therefore, only a quarter of them receive any treatment recommendations. This is an important area to address through the lens of occupational therapy as it is also reported that CRF is a frequent barrier to ones participation in their daily activities. Community-based support services like the CSC STL are emerging to fill the gap in cancer care. The CSC serves various members in the community who have been impacted by cancer. They have connections with local hospitals and staff who refer patients and family members to this organization for support. CSC works with contracted licensed mental health professionals, art therapists, cooking instructors, fitness instructors and various volunteers to meet the needs of their members of all ages. They offer a young adult program as well to target ages 18-40 who are experiencing cancer at this stage of life. This age range tends to have a busier lifestyle as they often have young children, work full time, and are involved in extracurricular. CSC also offers a family program with activities geared towards both parents and kids to bring families together who are experiencing a similar situation. AN EDUCATIONAL SERIES ON SYMPTOM MANAGEMENT 6 For this capstone project, a needs assessment was conducted through zoom interviews with the CSC program development staff which is made up of three social workers. It was discovered that educational presentations are popular amongst their members. They reported that these individuals enjoy feeling supported through discussions, expanding their knowledge, and collecting resources to utilize throughout their cancer survivorship. Although their educational presentations are popular and effective, they have never implemented an educational series, presenting topics that build on one another overtime. The staff identified topic areas for this educational program to meet the needs of their members are side effects most experienced by their members: cancer-related fatigue, cancer-related peripheral neuropathy, and cancer-related cognitive impairment. It is evident that there are physical and psychological needs not being met for cancer patients. Current research supports education on cancer and treatment itself for self-care of the side effects experienced with cancer, but less is known about education on management strategies and if they are effective from an occupational therapy perspective. Arunachalam et al. (2021) concluded that prior education on the disease and treatment has a positive correlation to self-care/management practice among participants. Grapp, et al. (2022) found similar support for online education to address psychosocial needs of cancer patients where the interventions could be helpful to implement these skills into everyday life. The aim of this DCE is to develop, implement, and evaluate an educational program on side effects and symptom management within cancer survivorship through the lens of occupational therapy. AN EDUCATIONAL SERIES ON SYMPTOM MANAGEMENT 7 Theoretical Framework The KAWA model was utilized to guide this doctoral capstone experience. This model focuses on the flow of harmony in ones life, looking not just at the person at the center, but the interconnectedness of their environment, nature and their personal life experiences (Cole & Tufano, 2020). Applying this to the CSC member population, my project addressed various symptoms of cancer that these individuals experience. I provided education and strategies to help manage these and continue their lives flow. Figure 1 displays a visual reference of the model and frame of reference applied to my capstone. The upstream of the river represents the past, or life before a member was impacted by cancer. The downstream of the river represents their life after being impacted by cancer. Rocks in the river represent impediments to lifes flow, so these would be the educational series topics I addressed. Driftwood in the river symbolizes rescuing someone from the rocks and these would be the management strategies I educated members on to combat the rocks that are affecting them. The sides and bottom of the river represent one's context, places where they interact so for this population it would be CSC, where they connect with others impacted by cancer. Their context can also be their support system, their home environment, and the hospital they receive/d treatment from. Additionally, I utilized the Health Belief Model (HBM) to further guide the implementation of the DCE. This model focuses on the individuals beliefs and cues to action contributing to the main behavior change action. Ones beliefs of developing the effects and/or symptoms of cancer and the severity of it, such as it affecting their physical and mental health further, influences their course of action. Action also depends on ones perception of benefits to action such as gaining coping skills and the barriers to action like a lack of resources or time (Luque, n.d.). It was important to understand these factors to know how to effectively implement my DCE to benefit the members. AN EDUCATIONAL SERIES ON SYMPTOM MANAGEMENT 8 Design & Implementation Based on the literature review and needs assessment conducted of this site, there was an unmet need of this cancer population. Many cancer patients are not aware of the symptoms that can occur or how to properly manage them (Abu El-Kass et al., 2021). Through collaboration with CSC STL, it was identified that this was also an unmet need of their members at their site and that educational programs are very popular amongst their members. This capstone used a pre-test post-test single group approach with self-reported surveys to examine the impact of an educational series on symptom management within the cancer population at CSC STL. Follow up surveys were sent out to those that attended the sessions to further assess their knowledge and implementation of the learned strategies for self-management. The surveys were optional, but encouraged, and anonymous to hide the identity of the participants. This method was chosen to evaluate if knowledge was gained on the side effects through the workshop, if they learned the strategies to manage them, and if they learned occupational therapys role within symptom management in cancer survivorship. The workshops were PowerPoint presentations compiled of research on the side effect, how it occurs and presents, management strategies and interactive activities with various discussion points throughout. The presentations were in collaboration with Dr. Katie Polo, my capstone faculty advisor, to have them professionally reviewed by an expert in the field. The primary long term goal of this program was to educate this population on various symptoms that can occur within cancer survivorship and provide them strategies for how to manage these from an occupational therapy perspective. Participants were recruited through various mediums to promote this series. An announcement was made in their education section of the quarterly newsletter for January-March 2023, with descriptions under each workshop for more information. Additionally, using their AN EDUCATIONAL SERIES ON SYMPTOM MANAGEMENT 9 member database, emails were sent about 2 weeks prior to the workshops with designed posters about the presentation. Targeted emails were sent to those who joined the Fitness in Survivorship'' class I was conducting as part of my capstone experience. Each workshop was 1.5 hours long and held via zoom due to the site still being hybrid with their immunocompromised members and the COVID-19 pandemic effects. I lead the workshops through education, guided personal experience discussions, and instructed various activities for self-management strategies for individuals to implement day-to-day. Participants were allowed to ask questions at the end or if they came up naturally during discussions. My contact information was provided at the end for follow-up appointments if participants were interested in continuing a discussion or learning more about how to implement these strategies into their daily routines. The first workshop was Cancer-Related Fatigue & Energy Conservation Techniques and it was a lunch and learn held during week 3. The second workshop was Coping with Cancer-Related Cognitive Impairments and it was held in the afternoon during the 7th week. The third workshop was Managing Cancer-Related Peripheral Neuropathy and it was held in the afternoon during the 10th week. The day after each workshop, a follow-up thank you email was sent to participants. Members would reply and I would respond to questions as needed. No members scheduled follow-up meetings. AN EDUCATIONAL SERIES ON SYMPTOM MANAGEMENT 10 Outcomes For this capstone, these workshops were open to the members of the Cancer Support Community of St. Louis to register individually or for all three. Each workshop had varying member attendance. Within the workshops, a pre and post survey were collected anonymously to rate the effectiveness of knowledge and likeliness they would implement management strategies. These numbers also varied as to how many replied to each the pre and the post survey. No members reached out for follow-up appointments following the workshops. The first workshop in January of 2023 on Cancer-Related Fatigue had 14 members attend. Eight responded to the pre-survey (57%) and six (42%) responded to the post survey. Figure 1 displays the average rating of each question on knowledge on the topic, demonstrating positive results in the understanding of the side effects, management strategies and if they would implement them, and an understanding of what occupational therapy is and how it can help. Two members responded to a follow-up survey where they stated they had an increased awareness of their fatigue and began to incorporate exercise into their lifestyle again. The second workshop in February of 2023 on Cancer-Related Cognitive Impairments had 18 members attend. Nine responded to the pre-survey (50%) and six (33%) responded to the post survey. Figure 2 displays the positive results in understanding of the side effects, management strategies and if they would implement them, and an understanding of what occupational therapy is and how it can help for this topic. One member responded to the follow-up survey with 100% learned knowledge and implementing strategies. They also stated the presentation covered detailed information so they were able to better understand cancer-related cognitive impairments. Lastly, the third workshop in March of 2023 on Cancer-Related Peripheral Neuropathy had 22 members attend. 17 responded to the pre-survey (77%) and 10 responded to the post survey (45%). Figure 3 displays AN EDUCATIONAL SERIES ON SYMPTOM MANAGEMENT 11 the results, demonstrating positive outcomes in understanding the side effects, management strategies and if they would implement them, and an understanding of what occupational therapy is and how it can help. Two members responded to the follow-up survey with 100% learned knowledge and implementing strategies. One member mentioned a technique that was not helpful to them was the frozen gloves during chemotherapy and another member expressed interest in trying out other management strategies mentioned in the workshop. Every week, a gentle fitness class was implemented and promoted to all of the CSC members as part of the capstone experience. This program was also highlighted in the workshop presentations as a management technique and overall health improvement. The class enrollment ranged from 2-7 members weekly on both zoom and/or live in person. Formative assessment was performed after each class to ask members for feedback. Many members reported they felt good afterwards and were enjoying the class. Members did not provide any constructive feedback, although it was suggested to record the classes for later viewing or to partake in this class more than once a week. This feedback was taken into consideration and workout videos were made for the organization to promote as a resource on their website which was received with great enthusiasm. AN EDUCATIONAL SERIES ON SYMPTOM MANAGEMENT 12 Summary Those impacted by cancer are growing in number, as well as the physical, emotional and psychosocial tolls they face. The cancer journey they experience impacts their daily participation and performance in everyday tasks. Side effects like fatigue, cognitive impairments, and peripheral neuropathy all affect their quality of life. This population has minimal knowledge on these side effects that can occur and how they can impact them as well as how to manage them (Sae'd Abu El-Kass et al., 2021). It is evident that education on these topics demonstrates improved self-care/management practices, but there is still a lack of understanding as to how this education is best presented for carryover to improve ones quality of life (Arunachalam et al., 2021). Once this gap was identified, a needs assessment for the Cancer Support Community St. Louis discovered a desire for more education on these popular symptom areas. A program was developed to specifically address education on symptoms and management strategies for these in order to increase understanding of them and self-manage them to be able to participate in daily tasks without their compromise. Three workshops were provided on fatigue, cognitive impairments, and peripheral neuropathy. Members were asked to complete a pre and post survey around the workshop. The results identified that many members did not understand these symptoms nor how to manage them. From the workshops, members gained more understanding of the factors that went into each side effect, the symptoms that can occur, how to manage them, and occupational therapys role in management as well. Members reported an increase in confidence for self-advocacy and shared valuable resources with one another, gaining support from others and not feeling alone in their cancer journey. An area of improvement for the project could be sending out materials prior to the workshop so members could take notes and develop questions beforehand. AN EDUCATIONAL SERIES ON SYMPTOM MANAGEMENT 13 Conclusion The primary aim of this program was to educate members of a community-based cancer support center (CSC STL) on the side effects that can occur in cancer survivorship and how to manage them through strategies. Through this program, members not only learned more about management strategies for symptoms, but also had guided discussions about their symptoms with other individuals experiencing them. This brought a sense of feeling more understood and also learning about resources others had tried. This program helped CSC STL members gain more understanding of three common side effects that can occur as well as all of the symptoms from them. By learning about the factors that play a role in these side effects, identifying symptoms that can occur, and management strategies, members gained more knowledge on how to selfmanage these symptoms in order to continue or return to participating in their daily activities. These workshops were very highly attended and well-liked by the feedback, further demonstrating the importance and need of these educational presentations. The CSC STL will continue to hold educational workshops for their members with this new awareness of how liked they are, especially when held by medical professionals. In the realm of occupational therapy, cancer care is an emerging practice area with a growing need as demonstrated by the lack of knowledge these members reported prior to the educational workshops. Although occupational therapists have a defined role in cancer care, there is still limited research on occupational therapy in cancer care from a rehabilitation standpoint for management and chronic care now. Many studies focus on certain stages rather than the full continuum of care within survivorship. Occupational therapy can address areas such as fatigue, neuropathy, intimacy issues, pain, cognitive impairments and many more. Further development of these community-based programs are needed to continue to address these gaps in care for this population. AN EDUCATIONAL SERIES ON SYMPTOM MANAGEMENT 14 References Abu El-Kass, S., Ragheb, M. M., Hamed, S. M., Turkman, A. M., & Zaki, A. T. (2021). Needs and self-care efficacy for cancer patients suffering from side effects of chemotherapy. Journal of Oncology, 2021, 19. https://doi.org/10.1155/2021/8880366 American Cancer Society. (2023). Cancer facts & figures 2023. https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/2023cancer-facts-figures.html Arunachalam, S. S., Shetty, A. P., Panniyadi, N., Meena, C., Kumari, J., Rani, B., Das, P., & Kumari, S. (2021). Study on knowledge of Chemotherapy's adverse effects and their selfcare ability to manage - the cancer survivors impact. Clinical Epidemiology and Global Health, 11, 100765. https://doi.org/10.1016/j.cegh.2021.100765 Cancer.Net. What is cancer survivorship? (2022, June 30). https://www.cancer.net/survivorship/what-cancer-survivorship Cole, M. & Tufano, R. (2020). Applied theories in occupational therapy: A practical approach. (2nd Ed.). Thorofare, N.J.: SLACK Inc Drott, J., Bjrnsson, B., Sandstrm, P., & Berter, C. (2022). Experiences of symptoms and impact on daily life and health in hepatocellular carcinoma patients. Cancer Nursing, 45(6), 430437. https://doi.org/10.1097/ncc.0000000000001044 Efverman A. (2023). Physical, Leisure, and Daily Living Activities in Patients Before, During, and After Radiotherapy for Cancer: Which Patients Need Support in Activities?. Cancer AN EDUCATIONAL SERIES ON SYMPTOM MANAGEMENT 15 nursing, 10.1097/NCC.0000000000001187. Advance online publication. https://doi.org/10.1097/NCC.0000000000001187 Faaij, M., Schoormans, D., & Pearce, A. (2022). Work, daily activities and leisure after cancer. European Journal of Cancer Care, 31(4). https://doi.org/10.1111/ecc.13596 Grapp, M., Rosenberger, F., Hemlein, E., Klein, E., Friederich, H.-C., & Maatouk, I. (2022). Acceptability and Feasibility of a Guided Biopsychosocial Online Intervention for Cancer Patients Undergoing Chemotherapy. Journal of Cancer Education : The Official Journal of the American Association for Cancer Education, 37(1), 102110. https://doi.org/10.1007/s13187-020-01792-4 Henderson, F. M., Cross, A. J., & Baraniak, A. R. (2019). A new normal with chemobrain: Experiences of the impact of chemotherapy-related cognitive deficits in long-term breast cancer survivors. Health Psychology Open, 6(1), 2055102919832234. https://doi.org/10.1177/2055102919832234 Kessels, E., Husson, O., & van der Feltz-Cornelis, C. M. (2018). The effect of exercise on cancer-related fatigue in cancer survivors: a systematic review and meta-analysis. Neuropsychiatric disease and treatment, 14, 479494. https://doi.org/10.2147/NDT.S150464 Luque, M. (n.d.). Behavior change theory: Help clients stick with their program. NASM. https://blog.nasm.org/behavior-change-and-motivation/behavior-change-science Rohilla, K. K., Batra, A., & Kalyani, C. V. (2020). Incidence and severity of self-reported chemotherapy side-effects in patients with hematolymphoid malignancies: A cross- AN EDUCATIONAL SERIES ON SYMPTOM MANAGEMENT 16 sectional study. Cancer Research, Statistics, and Treatment, 3(4), 736. https://doi.org/10.4103/crst.crst_87_20 Sae'd Abu El-Kass, Marwa M. Ragheb, Safaa' M. Hamed, Anas M. Turkman, Azhar T. Zaki. (2021). Needs and Self-Care Efficacy for Cancer Patients Suffering from Side Effects of Chemotherapy. Journal of Oncology, vol. 2021, Article ID 8880366, 9 pages, 2021. https://doi.org/10.1155/2021/8880366 Savina, S., & Zaydiner, B. (2019). Cancer-Related Fatigue: Some Clinical Aspects. Asia-Pacific Journal of Oncology Nursing, 6(1), 79. https://doi.org/10.4103/apjon.apjon_45_18 Van Dyk, K., & Ganz, P. A. (2021). Cancer-Related Cognitive Impairment in Patients With a History of Breast Cancer. JAMA, 326(17), 17361737. https://doi.org/10.1001/jama.2021.13309 Wang, T., Molassiotis, A., Chung, B. P., & Tan, J.-Y. (2018). Unmet care needs of advanced cancer patients and their informal caregivers: A systematic review. BMC Palliative Care, 17(1). https://doi.org/10.1186/s12904-018-0346-9 Yale Medicine. (2022, February 4). Side effects of cancer treatment. Yale Medicine. Retrieved January 30, 2023, from https://www.yalemedicine.org/conditions/side-effects-cancertreatment AN EDUCATIONAL SERIES ON SYMPTOM MANAGEMENT 17 Figure 1 Theoretical Framework AN EDUCATIONAL SERIES ON SYMPTOM MANAGEMENT 18 Figure 2 January 2023 - Cancer Related Fatigue & Energy Conservation Techniques Figure 3 February 2023- Coping with Cancer-Related Cognitive Impairments Figure 4 March 2023 - Managing Cancer-Related Peripheral Neuropathy AN EDUCATIONAL SERIES ON SYMPTOM MANAGEMENT 19 Appendix A DCE Weekly Planning Guide Week 1 DCE Stage Weekly Goal Orientation 1) Complete orientation by the end of the week 2) Complete Needs Assessment by the end of the week 3) Attend other CSC programs by the end of the week 2 Screening/ Evaluation 1) Complete search of literature for program evaluation measures by midweek 2) Prepare for first workshop Objectives Tasks Meet with site mentor, other staff to introduce myself and educate them on why I am here/what I will be doing for the 14 weeks Set up meeting with site mentor and advisor Discuss supervision plan and update MOU with site mentor Understand site environment/where to work/dress code/etc Update goals for MOU Determine who to meet with and what questions to ask and set up meeting Review other programs and attend to get acquainted with other facilitators and members Review calendar and register for other CSC programs, attend class and introduce myself Establish Outcome assessment Review outcome assessments with site mentor & faculty mentor Review presentation with site mentor and advisor Join young adult cooking class to get acquainted with these 1/10 1/12 Ensure that all paperwork for orientation is complete Finalize questions for Needs Assessment Finalize workshop presentation Date Complete 1/9 Set up meeting with site mentor and advisor to review presentation Register for cooking class and introduce self to instructor and members 1/18 1/20 AN EDUCATIONAL SERIES ON SYMPTOM MANAGEMENT 3 presentation by end of the week members and the cooking facilitator 3) Participate in young adult cooking class in the middle of the week Finalize MOU 3) Turn in MOU by 1/20 Implementation 1) Turn in Introduction draft by 1/23 Finalize Introduction draft Finalize notes and surveys for first workshop 2) Present first workshop on 1/24 Meet with site mentor and follow up with members 3) Review/receive feedback on workshop by end of week 4 Implementation 1) Turn in Background draft by 1/30 2) Respond to email responses from first Finalize Background draft Connect with members and provide answers or resources to their follow-up questions Layout the next workshop powerpoint 20 Meet with mentor to finalize MOU and turn in with signatures Complete research on the cancer population and overview of project for Introduction draft 1/23 Write out notes for more information on slides, copy survey links 1/27 1/24 Ensure zoom access and screen sharing for workshop Schedule meeting with site mentor for feedback Send follow up email to participants Complete research on CSC and member population and need for project 1/30 2/1 Complete research on information 2/3 or resources for members Reply to member emails AN EDUCATIONAL SERIES ON SYMPTOM MANAGEMENT workshop by mid-week 5 3) Begin working on next workshop presentation by the end of the week Implementation 1) Turn in Design and Implementation draft 2/6 2) Complete half of next workshop presentation by the end of the week 21 Create next workshop powerpoint and complete introduction slides Understand terminology for data collection Research proper terminology for survey collection Draft up definitions, causes, and symptoms for next workshop Research definitions, causes and symptoms for next workshop Draft up app and technology slides for management strategies 2/6 2/10 Research apps and technology for management strategies 3) Begin laying out management strategy slides by the end of the week 6 Implementation 1) Finalize second presentation by the end of the week 2) Contact young adult members Finalize management strategies and support resources for presentation Finalize workout for class Contact members to understand their current level of fitness and Research other management strategies and support within community for further medical care Get contact list of young adult members from staff member 2/15 2/17 AN EDUCATIONAL SERIES ON SYMPTOM MANAGEMENT 7 signed up for my fitness pop up class by midweek Implementation 1) Present second workshop on 2/21 2) Lead young adult fitness pop up class on 2/22 3) Complete midterm evaluation by the end of the week remind them about the pop up class Email/call young adult members Finalize notes and surveys for workshop Write out notes for more information on slides, copy survey links 2/21 Research and print off warm up and cool down exercises and resources for young adult class 2/24 Provide resources to fitness class participants Follow up with workshop and fitness class participants Discuss if the workshops presented and fitness classes are meeting the needs of CSC Discuss positive and constructive feedback 8 Implementation 1) Begin third presentation by mid-week 2) Begin Outcomes draft by mid-week 22 Create introductory and definition slides Connect with health fair attendees and spread awareness of CSC Obtain at least 3 new member 3) Represent CSC contact information at health fair on 3/1 and 3/2 2/22 Get contact information from zoom and live attendance, send follow up email and resources to participants Set up meeting with site mentor for midterm evaluation and second workshop feedback Create third powerpoint presentation with introductory slides Research definitions, causes, and symptoms Gather supplies for health fair and directions/parking for health fair Organize elevator speech of CSC and my role to increase awareness 3/1 3/2 AN EDUCATIONAL SERIES ON SYMPTOM MANAGEMENT 9 Implementation 1) Complete third presentation by the end of the week 2) Create visual graph for the Outcomes draft by the end of the week 10 Implementation 1) Turn in Outcomes draft by 3/13 Implement Ohio State resources into powerpoint and finalize management strategies Research Ohio State management techniques further and other strategies for workshop Prepare resources to email to members after workshop presentation Scan handouts and prepare to email members Finalize notes for workshop Write out slides and further talking points for information Finalize current data for analyzing Research Qualtrics for creating visuals of data Finalize Outcomes draft Finalize notes and surveys for third presentation 2) Present third workshop on 3/14 Follow-up with workshop participants 11 Implementation 1) Turn in Dissemination Plan on 3/20 2) Complete final graphs for 23 Enter in data on Qualtrics and create graphs Format graphs correctly for finalizing the Outcomes draft Write out notes for more information on slides, copy survey links 3/10 3/13 3/14 Schedule meeting with site mentor for workshop feedback Finalize dissemination plan Send follow up email to participants Research dissemination methods Finalize graphs for analyzing survey data Reformat surveys on Qualtrics and recreate graphs 3/20 3/24 AN EDUCATIONAL SERIES ON SYMPTOM MANAGEMENT 12 analyzing data by the end of the week Implementation 1) Create new graphs for ease of understanding by the end of the week 2) Begin creating educational handouts by the end of the week 13 3) Begin laying out fitness class for online recordings by the end of the week Discontinuation 1) Begin creating dissemination materials by the end of the week 2) Begin working on Abstract, Summary, and Conclusion drafts by the end of the week 3) Complete fitness class Format graphs directly from Google Forms Layout educational handouts of each workshop for online member resources Create a warm, full body workout, and cool down layout for fitness class recordings 24 Carry over current data from surveys into excel and create graphs 3/31 Access Canva and transfer/reduce workshop information Research more on fitness and workout routines within cancer survivorship Type up exercises for each video recording Layout workshop information for handouts during dissemination Access Canva, write out each program and its information: time, attendees, survey results Continue editing educational handouts Review spelling and formatting for educational handouts on Canva Outline Abstract, Summary and Conclusion drafts Refer back to introduction and background for summary draft Finalize warm up, full body workout, and cool down After summary and conclusion exercises for recordings drafts, outline Abstract draft 4/7 AN EDUCATIONAL SERIES ON SYMPTOM MANAGEMENT 14 Dissemination layout for online recordings by the end of the week 1) Turn in Abstract, Summary and Conclusion drafts on 4/10 2) Disseminate to site at Thursday staff meeting 3) Provide educational handouts at Thursday staff meeting 4) Record fitness videos by the end of the week 5) Complete final evaluation by 4/14 Finalize Abstract, Summary and Conclusion drafts Finalize graphs for visual data analysis in excel Finalize educational handouts on Canva for dissemination to provide resources for members online Complete write up of workout routines for recordings Discuss if the workshops and fitness classes met the needs of CSC Discuss positive and constructive feedback 25 Review and edit order of exercises to ensure breaks and overall flow during recordings Ensure correct formatting for Abstract, Summary and Conclusion drafts and turn in 4/10 4/13 Ensure all data is entered on excel 4/14 and graphs are formatted correctly Print handouts of capstone project and outcomes from Canva to present Set up time/meeting to record on zoom for online resources Record workouts Schedule meeting for final evaluation with site mentor  ...

... Developing Adverse Childhood Experiences Education Program to Increase Caregiver Confidence in Providing Adequate Care and Support Anne Mari West May 1, 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Dr. Taylor Gurley, MS, OTD, OTR DEVELOPING ADVERSE CHILDHOOD EXPERIENCES EDUCATION PROGRAM Abstract Adverse Childhood Experiences (ACEs) are when a child experiences one or more instances of trauma, abuse, parental mental illness, or exposure to poverty early in life. Exposure to these experiences can negatively impact a childs mental and physical development. This doctoral capstone experience (DCE) is the creation of an online and in-person education program on ACEs for the staff of a non-profit organization school and daycare to learn how to adequately support children when the negative effects of those experiences prevent them from being successful in their daily occupations. Pre and Post surveys were used along with the in-person course session to collect data on the effectiveness of the education program. The data from the in-person course session demonstrated that the course was effective in educating staff on ACEs and increasing their confidence to use that knowledge to combat the negative effects they recognize using various interventions. 2 DEVELOPING ADVERSE CHILDHOOD EXPERIENCES EDUCATION PROGRAM Introduction Shepherd Community is a faith- based non-profit organization located on the eastside of Indianapolis, Indiana. Their mission is to break the cycle of poverty that is seen in the eastside community through providing stability to and meeting the critical needs of those living in poverty. This process of supporting those in poverty begins in the daycare and school levels, where there is a large group of children experiencing trauma, such as poverty, at a young age, that is negatively affecting how they develop mentally and physically. Hence why it is important to think about early intervention in this setting. Early intervention plays a critical role in influencing a childs life trajectory and how they mentally develop in the following years (Rischel et al., 2019). My Doctoral Capstone Experience (DCE) is the creation of a program that educates the staff of Shepherd Academy and Minnie Hartmann Daycare Center on adverse childhood experiences and how to adequately support children growing up in poverty when the negative effects of adverse childhood experiences (ACEs) prevent them from being successful in their daily occupations. ACEs are when an individual experiences some form of abuse, neglect, or household dysfunction before the age of eighteen. This program will be used as an early intervention technique to equip staff with the tools to create a safe environment for the children to thrive in, a solid support system to help the children face their mental health roadblocks, and a foundation for them to continue to build a better life for themselves. This paper will address what the staff knew prior to the development of the program, the research used to develop the program, and how staff felt following the program's completion. 3 DEVELOPING ADVERSE CHILDHOOD EXPERIENCES EDUCATION PROGRAM Background Draft Current data collected by the United States Census Bureau states that the percentage of those suffering in poverty in Indianapolis is 16.4% (U.S. Census Bureau, 2022). Specifically on the eastside of the city, about half of the population is living at or below the poverty level; this is the community Shepherd strives to serve (Shepherd Community Center, 2021). Currently, they serve more than 1,000 individuals and families on the eastside of Indianapolis. Their service includes full-day/after-school care, food pantry, support groups, health care access, public safety support, and counseling. Due to the organization consisting of a preschool, elementary school, and daycare, the staff have an opportunity to mentor more than 500 children per year. Research has shown that being exposed to poverty at a young age can have a detrimental effect on how a child develops. Those living in poverty have little access to proper nutrition, safe living conditions, and environments that enhance learning (Justice et al., 2019). This results in children being deprived in the areas of education, mental health, and physical health. A recent study found that there is a correlation between poverty and the lack of moral development in children as they grow, which results in a higher risk of those children turning to crime and violence as adults (Parveen et al., 2018; Justice et al., 2019). The economic hardships that are faced by families not only increase the immoral activities children will participate in, but will also increase the amount of stress they can experience (Crouch et al., 2019). The high levels of stress parents typically experience will trickle down to the children and can sometimes lead to a lack of intimate nurturing and attention towards the child. In certain situations, this lack of nurturing and attention can evolve into abuse or neglect of the child (Nwobodo, 2022; Crouch et al., 2019). This deprivation of affection and warmth from parents has a negative impact on how a childs mind develops which in turn will affect how a child effectively communicates and what 4 DEVELOPING ADVERSE CHILDHOOD EXPERIENCES EDUCATION PROGRAM behaviors they use in different situations. It has been discovered that poverty, and the negative effects that result from it, have a detrimental impact on the development of the amygdala and hippocampus. The amygdala and hippocampus are responsible for the regulation of stress and emotional processing in the brain (Nwobodo, 2022). The poor development of each can lead to a child developing antisocial behavior, a lack of self-confidence, conduct disorders, and increased aggression (Luby et al., 2013; Luby et al., 2019). These negative experiences that result from poverty can be included under a category called Adverse Childhood Experiences (ACEs). Those that experience ACEs see debilitating mental and physical effects that continue into adulthood. A study discovered that parents that experienced, and continue to suffer from, adverse experiences tend to experience increased amounts of parental distress, which can lead to their children experiencing ACEs (Steele et al., 2016; Crouch et al., 2019). This is something that contributes to the generational cycle of poverty. Adverse Childhood Experiences Adverse Childhood Experiences are when children experience trauma, parental mental illness, or exposure to poverty early in life. A child could also be exposed to more than one of these at a time (Whitney & Cronin, 2019). Through years of research, practitioners have discovered how these experiences can negatively impact a childs life and growth (Barch et al., 2018). Exposure to these events can result in a higher risk for a wide range of mental disorders and of poor health behaviors. When looking at the development of the brain following exposure, you will see deficits in the prefrontal lobes structure and function. These impairments include damage to the regions of the brain that control emotional regulation and impulse control (Barch et al., 2018; Luby et al., 2019). Many of the children that currently attend Shepherd Academy suffer from 5 DEVELOPING ADVERSE CHILDHOOD EXPERIENCES EDUCATION PROGRAM post-traumatic stress disorder, anxiety, and various other mental illnesses as a result from an exposure of an ACE. These mental disorders could have a negative impact on the childs growth and future. Children that have suffered from at least three different ACEs were four times more likely to experience health issues, six times more likely to have behavioral problems and three times more likely to experience academic failure when compared to others in their age group (Sciaraffa et al., 2018; Turney, 2020). ACEs have also been linked to the development of chronic health problems, mental illness, and substance abuse in adulthood (Matjasko et al., 2022; Turney, 2020). It has been shown that children are more likely to be resilient to the adverse effects that result from traumatic experiences, if they have a caregiver that helps them regulate their emotions, supports their educational needs, and provides them with a safe environment to thrive in (Humphreys et al., 2021). Taking the steps to prevent a child from experiencing more ACEs in their lifetime and enhancing Positive Childhood Experiences (PCEs) have the potential to promote lifelong health benefits so that they will be able to reach their full potential (Qu et al., 2022). PCEs increase the likelihood of a child achieving a healthy development and allow them to have a healthy connection with others and themselves. By creating opportunities for PCEs to happen in a childs life, there is potential to lessen the impact ACEs have on current and future health (Qu et al., 2022). Therefore, it is important to implement early intervention techniques through the educators found at this setting. The educators at this school system are in a position where they can easily recognize and lessen the impact ACEs have on a child's mental development and individual growth (Sciaraffa et al., 2018). They have an opportunity to provide an environment that is safe, protected and allows a child to feel a sense of belonging (Matjasko et al., 2022). 6 DEVELOPING ADVERSE CHILDHOOD EXPERIENCES EDUCATION PROGRAM Providing that Shepherd Community will have a better chance to break the cycle of poverty when a child is fully supported in their educational, physical, and mental needs. Model and Theory Occupation Based Model The model that was best fit for this doctoral capstone experience (DCE) was the TrustBased Relational Intervention Model (TBRI). This model was chosen due to its focus on training caregivers of at-risk youth in providing effective support and treatment for them (Purvis et al., 2017). A recent study demonstrated how an evidence-based program, in which an educator implementing interventions such as yoga or deep breathing exercises, resulted in improvement in a childs mental health and in their motivation to participate in their occupations (Lin et al., 2021). Similarly, this doctoral capstone experience explored Occupational Therapys role in educating staff on attending to childrens needs following adverse childhood experiences (ACEs) at Shepherd Community. The TBRI helped ensure that the program taught the staff how to meet the childrens physical, emotional, and behavioral needs were being met (Stipp & Kilpatrick, 2021). Frame of Reference The frame of reference (FOR) chosen to guide this DCE was the Intentional Relationship Model (IRM). IRM is when the therapist can effectively manage their relationship with the client to improve occupational engagement. (Gorenburg & Taylor, 2020). A 2018 study demonstrated that increased education in caregivers serving dementia patients showed an improvement in the patients participation in everyday occupations (Raber et al., 2019). This FOR worked well as a companion to the model of TBRI due to this DCE being focused on increasing the staffs 7 DEVELOPING ADVERSE CHILDHOOD EXPERIENCES EDUCATION PROGRAM knowledge in ACEs in order to improve the childrens overall care rather than providing interventions directly to the children. The therapist increased the staffs engagement in their occupation to improve the occupational engagement of the children. Project Design & Implementation This project consisted of the creation and implementation of a five-section education program on the topic of ACEs. This course was developed on PowerPoint and consisted of five sections; brain development, infant/toddler, elementary, middle/high school, and adult. The brain development section focused on how ACEs affect an individuals brain development and how those negative effects continue to affect them throughout their lifetime. The infant/toddler, elementary, middle/high school and adult sections focused on how the negative effects of ACEs are typically presented in this age range and actions staff members can take to help combat those negative effects in the childs daily routine at the daycare, school, or after-school care settings. A crash course PowerPoint video was also provided to Shepherd in order to provide quick education on ACEs to occasional volunteers rather than requiring them to complete the extensive course. Prior to the implementation of this education program, a survey was sent out to gather data on what staff currently know about ACEs, how confident they feel in their knowledge on ACEs, and how confident they feel in using that knowledge to create safe environments for children to learn in. This survey provided a baseline for all staff members that interact with children daily and allowed me to see if there was improvement following the completion of the online education courses. A post-education program survey was also provided at the end of the in-person session to measure an increase in their confidence and knowledge on ACEs in order to create environments for the children to thrive in. 8 DEVELOPING ADVERSE CHILDHOOD EXPERIENCES EDUCATION PROGRAM A one-hour in person education session was conducted with 10 staff members from the academy, daycare, and after-school programs. They completed the pre-course survey prior to attending the in-person course. At the end of the session, they were given a QR code to access the post-session survey. If they were unable to complete the survey online, they were given a paper copy of the survey to complete before leaving. Following the completion of this in-person session, all staff at Shepherd Community were given access to the online version of this course. The online version consisted of video presentations of the PowerPoints, and end-of-section quizzes. Staff that signed up for the online version of the course were asked to complete the presurvey and post-survey as well. Challenges of implementing this program were determining the appropriate time to conduct an in-person session, and the number of staff completing the pre/post surveys. It was difficult determining a time to gather staff for an in-person session due to the staff being in many different disciplines. Many of the staff have various jobs and responsibilities that make it difficult for them to attend a session during the day and after regular hours. Due to the pre-survey being sent to staff via email, many of them forgot to complete it prior to the in-person session. Successes of implementing this program were that 10 staff attended the in-person session and provided information to improve the online course that future staff will take. The in-person session allowed me to ensure that those who attended did complete both surveys before leaving the in-person session. Outcomes Pre-Survey and Post-Survey results were analyzed to determine whether there was an increase in confidence and knowledge following the completion of ACEs education program. Many staff members that completed the surveys and attended the in-person session work with children 9 DEVELOPING ADVERSE CHILDHOOD EXPERIENCES EDUCATION PROGRAM between the ages of one through thirteen. Around 66.75% of the participants had not heard of or been educated on ACEs prior to their participation in this education program. In the pre-survey, staff were asked to take the ACEs Score Exam to determine if they had experienced any traumatic experiences throughout their childhood, whether they were aware of the term or not. Fifty percent of the staff had a score of zero, ten percent had a score of one, twenty percent had a score of two, ten percent had a score of five, and ten percent had a score of 6. This indicates that half of the staff have experienced trauma in their childhood and could relate to what the children attending the school/daycare are currently experiencing. Figure 1 (See Appendix A) illustrates the increase of confidence in the staffs knowledge of ACEs following them attending the inperson session. These results show increased education and knowledge retention of ACEs following the completion of the course. Figure 2 (See Appendix A) illustrates the increased confidence in recognizing the negative effects that result from ACEs. This indicates that staff feel more confident in their ability to recognize how the negative effects of ACEs present in a child as they grow up than they did prior to attending the in-person session. Figure 3 (See Appendix A) illustrates the increase of confidence in knowing and implementing interventions to the environment or a situation. This indicates that the staff feel more knowledgeable in what they can do to change the environment or situation a child is in that is negatively affecting them. Summary The impact ACEs have on children can be seen throughout their lifetime creating a negative spiral effect that can be paused and improved through the development of a positive relationship with at least one adult. Hence why it is so important that adults working with children have the knowledge and means to create those safe/positive relationships with the children that have experienced trauma. Shepherd community directly impacts children that are living in poverty and 10 DEVELOPING ADVERSE CHILDHOOD EXPERIENCES EDUCATION PROGRAM are experiencing trauma but does not have an education program to educate their staff on how to work with those children and how to combat the negative effects of ACEs. This project consisted of creating an in-person and online education program that can be utilized at Shepherd to educate their staff on Adverse Childhood Experiences. The in-person session was used to collect data on the effectiveness of the course and the online-version will allow the course to be presented when it is needed. The data from the in-person course demonstrated that it was effective in educating staff on ACEs, building their confidence in recognizing the negative effects of ACEs, and developing safe environments for the children to grow in. This ensures that the online course will also be effective in educating the staff and building their confidence in caring for the children when it comes to ACEs. Shepherd plans to implement this online-education course into their orientation for all incoming staff to ensure their students are receiving the best possible care. Conclusion This doctoral capstone experience consisted of developing and presenting an education program on Adverse Childhood Experiences. This education program was then translated into an online course so it could be used following the completion of the capstone experience. Shepherd Community did not have an education program on ACEs prior to this project, so many staff members were unaware of it and learned through seeing the children react to their trauma. This proved to be an issue, due to the primary intervention on ACEs being a stable relationship with an adult. This stable relationship could not be made if the adult was unaware of ACEs, how it affects the children and what they can do to help combat those effects. Though this program is up to date with the current research on ACEs, future redevelopment of the program will be needed to make sure the most accurate data and interventions are being presented to staff. 11 DEVELOPING ADVERSE CHILDHOOD EXPERIENCES EDUCATION PROGRAM References Barch, D. M., Belden, A. C., Tillman, R., Whalen, D., & Luby, J. L. (2018). Early Childhood Adverse Experiences, Inferior Frontal Gyrus Connectivity, and the Trajectory of Externalizing Psychopathology. Journal of the American Academy of Child and Adolescent Psychiatry, 57(3), 183190. https://doi.org/10.1016/j.jaac.2017.12.011 Crouch, E., Radcliff, E., Brown, M., & Hung, P. (2019). Exploring the association between Parenting Stress and a child's exposure to adverse childhood experiences (aces). Children and Youth Services Review, 102, 186192. https://doi.org/10.1016/j.childyouth.2019.05.019 Gorenberg, M., & Taylor, R. (2014). The Intentional Relationship Model: A framework for teaching therapeutic use of self. OT Practice, 19(17), CE1-CE6. Home. Shepherd Community Center. (2021, September 7). Retrieved January 24, 2023, from https://shepherdcommunity.org/ Humphreys, K. L., King, L. S., Guyon-Harris, K. L., & Zeanah, C. H. (2021). Caregiver regulation: A modifiable target promoting resilience to early adverse experiences. Psychological Trauma: Theory, Research, Practice, and Policy. https://doi.org/10.1037/tra0001111 Justice, L. M., Jiang, H., Purtell, K. M., Schmeer, K., Boone, K., Bates, R., & Salsberry, P. J. (2019). Conditions of poverty, parentchild interactions, and toddlers early language skills in low-income families. Maternal and Child Health Journal, 23(7), 971978. https://doi.org/10.1007/s10995-018-02726-9 12 DEVELOPING ADVERSE CHILDHOOD EXPERIENCES EDUCATION PROGRAM Lin, C. L., Jin, Y. Q., Zhao, Q., Yu, S. W., & Su, Y. S. (2021). Factors Influence Students Switching Behavior to Online Learning under COVID-19 Pandemic: A PushPull Mooring Model Perspective. The Asia-Pacific Education Researcher, 30(3), 229245. https://doi.org/10.1007/s40299-021-00570-0 Luby, J. L., Tillman, R., & Barch, D. M. (2019). Association of timing of adverse childhood experiences and caregiver support with regionally specific brain development in adolescents. JAMA Network Open, 2(9). https://doi.org/10.1001/jamanetworkopen.2019.11426 Luby, J., Belden, A., Botteron, K., Marrus, N., Harms, M.P., Babb, C., Nishino, T., & Barch, D. (2013). The Effects of Poverty on Childhood Brain Development: The Mediating Effect of Care giving and Stressful Life Events. JAMA Pediatrics, 167(12), 1135-1142. Matjasko, J. L., Herbst, J. H., & Estefan, L. F. (2022). Preventing adverse childhood experiences: The role of Etiological, evaluation, and Implementation Research. American Journal of Preventive Medicine, 62(6). https://doi.org/10.1016/j.amepre.2021.10.024 Nwobodo, R. E. E. (2022). Poverty and the Challenges of Parenting: Issues and Prospects. Nnadiebube Journal of Philosophy, 2(2). Sciaraffa, M. A., Zeanah, P. D., & Zeanah, C. H. (2018). Understanding and promoting resilience in the context of adverse childhood experiences. Early Childhood Education Journal, 46(3), 343353. https://doi.org/10.1007/s10643-017-0869-3 13 DEVELOPING ADVERSE CHILDHOOD EXPERIENCES EDUCATION PROGRAM Steele, H., Bate, J., Steele, M., Dube, S.R., Danskin, K., Knafo, H., Nikitiades, A., Bonuck, K., Meissner, P., & Murphy, A. (2016). Adverse Childhood Experiences, Poverty, and Parental Stress. Canadian Journal of Behavioral Science, 48(1), 32-38. Stipp, B., & Kilpatrick, L. (2021). Trust-Based Relational Intervention as a Trauma-Informed Teaching Approach. International Journal of Emotional Education, 3(1), 6772. U.S. Census Bureau (2022). Indianapolis Community Survey 1-Year Estimates V2021. U.S. Department of Commerce. Retrieved April 24, 2023, from https://www.census.gov/quickfacts/fact/table/indianapoliscitybalanceindiana,US/PST04522 124 Parveen, R., Hussain, M., Majeed, I., Afzal, M., & Gilani, S. A. (2018). Influence of Poverty on Moral Development in Rural Community Lahore. International Journal of Social Sciences and Management, 5(3), 113-124. Purvis, K. B., Cross, D. R., Dansereau, D. F., & Parris, S. R. (2013). Trust-based Relational Intervention (TBRI): A systemic approach to complex developmental trauma. Child & Youth Services, 34(4), 360386. https://doi.org/10.1080/0145935x.2013.859906 Qu, G., Ma, S., Liu, H., Han, T., Zhang, H., Ding, X., Sun, L., Qin, Q., Chen, M., & Sun, Y. (2022). Positive childhood experiences can moderate the impact of adverse childhood experiences on adolescent depression and anxiety: Results from a cross-sectional survey. Child Abuse & Neglect, 125, 105511. https://doi.org/10.1016/j.chiabu.2022.105511 14 DEVELOPING ADVERSE CHILDHOOD EXPERIENCES EDUCATION PROGRAM Rishel, C. W., Tabone, J. K., Hartnett, H. P., & Szafran, K. F. (2019). Trauma-informed elementary schools: Evaluation of school-based early intervention for young children. Children & Schools, 41(4), 239248. https://doi.org/10.1093/cs/cdz017 Turney, K. (2020). Cumulative adverse childhood experiences and childrens health. Children and Youth Services Review, 119. https://doi.org/10.1016/j.childyouth.2020.105538 Whitney, R., & Cronin, A. (2019). Occupational therapy intervention: Developmental disability, adverse childhood experiences, and Developmental Systems Theory. SIS Quarterly Practice Connections, 4(3), 24. 15 DEVELOPING ADVERSE CHILDHOOD EXPERIENCES EDUCATION PROGRAM Appendix A: Figures Figure 1. Pre-Survey vs. Post-Survey Figure 2. Pre-Survey vs. Post-Survey Figure 3. Pre-Survey vs. Post-Survey 16 DEVELOPING ADVERSE CHILDHOOD EXPERIENCES EDUCATION PROGRAM 17 Appendix B: Doctoral Capstone Experience and Project Weekly Planning Guide Week 1 DCE Stage orientation Weekly Goal 1) Complete orientatio n by the end of the week. Objectives Meet with site mentor and discuss what the project will look like. Learn what the policies are at this site. Acquire badge and keys to easily access building. - - - 2 Screening/ Eval 1) Set up meetings with head staff members by the end of the week. 2) Determin e what will be Schedule meetings with head staff members and create questions to ask them regarding what they expect from the ACEs education program. - Tasks Date complete Meet with site mentors. Get picture taken for ID badge. Sign all paperwork that is required to be here. Interact and introduce myself with the staff that I share my workspace with. Begin making list of individuals I will need to have meetings with and what we will discuss. 1/13/23 Schedule meetings with heads of staff. Create questions to ask during meeting on ACEs and what they want to come 1/20/23 DEVELOPING ADVERSE CHILDHOOD EXPERIENCES EDUCATION PROGRAM asked/dis cussed in meetings. 3 4 Screening/ Eval Screening/ Eval out of the program. 1) Complete meetings with head staff members. 2) Gather data from staff members on what should be included in program. Conduct meeting with various heads of staff and ask them what they want the course to look like. - 1) Analyze data from meetings to create an outline of what the course will look like. Utilize the opinions/data gathered from the meetings to create an outline for the education course. - - - - 5 Implement ation 1) Research and gather sources for the creation of 18 Begin to gather resources needed for each main topic that will be addressed in course. - Gather opinions and data on what the ACEs course should include (write it all down). Complete all scheduled meetings with heads of staff. 1/27/23 Figure out what should be included in the course (main topics, etc..) Create a timeline of when you want to complete course. Find a program to create future course website. 2/1/23 Utilize various databases to find resources related to ACEs, poverty, etc 2/15/23 DEVELOPING ADVERSE CHILDHOOD EXPERIENCES EDUCATION PROGRAM education program - - 6 Implement ation 1) Complete brain developm ent and ACEs power point and resources . Complete the creation of handouts/resource s and the PowerPoint that relate to the main topic of brain development and ACEs. 7 Implement ation 1) Complete infant/tod dler and ACEs PowerPoi nt. Complete the creation of handouts/resource s and the PowerPoint that relate to the main topic of infant/toddlers and ACEs. - 8 Implement ation 1) Complete Complete the elementar creation of Gather at least 15 different resources for each topic. Ensure resources are current; within 5 years. -Create PowerPoint slides on ACEs and Brain Development. - Create handout/resources. - - 19 2/24/23 Create sections that state the how negative effects of ACEs present at this age and what interventions staff can use to combat them. Create resources that staff can easily access and understand information from PowerPoints. 3/3/23 Create sections that 3/8/23 DEVELOPING ADVERSE CHILDHOOD EXPERIENCES EDUCATION PROGRAM y, middle school, and ACEs PowerPoi nt and resources . handouts/resource s and the PowerPoint that relate to the main topic of brain development and ACEs. - 9 Implement ation 1) Complete high school, adulthoo d and ACEs PowerPoi nt and resources . 2) Schedule meeting to plan in-person session. Complete the creation of handouts/resource s and the PowerPoint that relate to the main topic of brain development and ACEs. Schedule a meeting with site mentors to decide when to conduct in-person session of course. - - 20 state the how negative effects of ACEs present at this age and what interventions staff can use to combat them. Create resources that staff can easily access and understand information from PowerPoints. Create sections that state the how negative effects of ACEs present at this age and what interventions staff can use to combat them. Create resources that staff can easily access and understand information from the PowerPoint. 3/14/23 DEVELOPING ADVERSE CHILDHOOD EXPERIENCES EDUCATION PROGRAM 10 11 Implement ation Implement ation 1) Complete ACEs crash course PowerPoi nt and resources . 2) Start recording video presentati ons of all PowerPoi nts. 3) Complete meeting to set date for in-person session. Complete the creation of handouts/resource s and the Crash Course PowerPoint that they can utilize for short-time volunteers. Have a meeting with site mentors to set a date for inperson presentation of course. 1) Complete recording video presentati ons of all PowerPoi nt. 2) Prepare for inperson presentati on of program. Complete the creation and editing of power point video presentations to be utilized on website. Prepare for the in-person presentation of the education program. - Schedule meeting with site mentors. - Create sections that are condensed versions of information found in all PowerPoints. Create resources that staff can easily access and understand information from the PowerPoint. Set a date for in-person session to be conducted with site mentors - - - - 21 3/17/23 Create 3/20/23 pre/post surveys that will analyze whether there was an increase in confidence and knowledge when it comes to ACEs. Complete and edit video versions of PowerPoint presentations. DEVELOPING ADVERSE CHILDHOOD EXPERIENCES EDUCATION PROGRAM 12 Implement ation Discontin uation 13 Screening/ Eval Dissemina tion - Create presentation cards/speakers notes for presentation. Present 3/24/23 program inperson. Check if postsurvey is up and ensure everyone completes it before leaving. Upload completed resources (PowerPoints, lecture videos, etc..) onto website. 1) Complete in-person presentati on of education program. 2) Have staff complete postsurvey. 3) Complete the creation of website to be used following the completi on of DCE. Hold in-person session of education program with the 10 staff that are available to attend. Ensure that each staff member completes postsurvey following the completion of education program. Upload and post website version of education course to be accessed following - 1) Analyze data from pre/post surveys. 2) Create Dissemin ation Plan by end of week. 3) Set up dissemin ation meeting Analyze data from pre/post surveys to determine if there was an increase of confidence. Create Dissemination plan and set up meeting with site mentors to go over that plan. - - - - Analyze the 4/10/23 difference seen in postsurvey compared to pre-survey. Complete Dissemination plan. Set up meeting with site mentors 22 DEVELOPING ADVERSE CHILDHOOD EXPERIENCES EDUCATION PROGRAM for next week. 14 Dissemina tion 1) Dissemin ate to Partner. 23 in Google calendar. Have a meeting with site mentors to disseminate project. - Complete dissemination meeting with site mentors. 4/14/23  ...

... Title: Occupational Performance Enhancement for Individuals with Dementia Scott Webb May 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Tricia Holmes, DHSc, MOT, OTR/L Abstract Dementia is a progressive cognitive decline that impacts an individual's ability to function independently (Duong et al., 2017). This cognitive decline often leads to these individuals being diagnosed with a mental health diagnosis like depression (Bergdahl et al., 2011) or anxiety (Spector et al., 2015). To better understand this issue, this project focused on educating the employees at the skilled nursing facility on tailoring the activities and occupations that the residents participate in to help improve the patient's quality of life, decrease their mental health problems, and to reduce the behaviors that occur when they are given tasks or activities that are too challenging for their cognitive level. A survey a used to assess the program. The findings were that the staff gained increased knowledge of how to care for an individual based on their ACL level, decreased caregiver burden when residents were appropriately cued, and increased resident participation when activities were cognitively appropriate. Introduction The site where this doctoral capstone experience took place is Ripley Crossing. Ripley Crossing is located in Milan, Indiana. The facility specialized in dementia care for senior residents and was the first facility to offer specialized dementia care to the community in the state of Indiana (Ripley Crossing, 2016). The facility has an on-site dementia coordinator who ensures that the staff who work in the dementia units receive training and must undergo up-to-date training once a month. Due to the emphasis that the site places on dementia care, there are three units specifically for individuals who have a dementia diagnosis. The first unit houses residents who are in the early stages of dementia, and the second unit houses residents who are in the moderate stages of dementia. The third unit houses residents who are in the late stages of dementia. This doctoral capstone experience explored using Allen's Cognitive Levels Assessment to determine the cognitive levels of the patients in the first and second dementia units, along with educating the employees at the skilled nursing facility on tailoring the activities and occupations that the residents participate in to help improve the patient's quality of life. Various cognitive assessments were used to ensure the validity of each resident's Allen's Cognitive Level. These assessments included the ACLS-5, the ADM-placemat, and the physical and communication portions of the RTI. A need for this program after the performance of a thorough needs assessment. It was quickly noted that the staff overburdened themselves by assisting in areas the residents could perform. This assistance often results in functional decline among the residents and staff burnout (Laver et al., 2016). The rest of this scholarly report will discuss background information regarding the aforementioned cognitive program, the theory and frame of reference that guided the development of the program, the program's design and implementation, and the program's outcomes. Background As mentioned in the introduction, this doctoral capstone experience explored using Allen's Cognitive Levels Assessment to determine the cognitive levels of the patients in the first and second dementia units. This project also focused on educating the employees at the skilled nursing facility on tailoring the activities and occupations that the residents participate in to help improve the patient's quality of life, decrease their mental health problems, and to reduce the behaviors that occur when they are given tasks or activities that are too challenging for their cognitive level. When thinking about working with individuals with dementia, it is essential to think about the diagnosis itself. Dementia is a cognitive decline which progressively worsens over time and results in individuals developing difficulties when performing their everyday activities. (Duong et al., 2017). Individuals with this diagnosis experience changes in their cognition, function, and behavior (Duong et al., 2017), and these individuals are also more likely to be diagnosed with depression (Bergdahl et al., 2011) and anxiety (Spector et al., 2015). The number of individuals with the diagnosis is even higher if they live in a residential care facility because individuals with dementia are given tasks and activities, whether put on by the activities department or the self-care tasks they are expected to perform, that is too difficult for them to perform based on their cognitive level. To combat this issue, protocols must be developed to meet the cognitive capabilities of individuals diagnosed with dementia (Weise et al., 2018). Through these protocols, individuals will be able to participate in leisure activities which have been proven to alleviate the symptoms of depression in individuals formally diagnosed with dementia (Cheng et al., 2012). These activities allow individuals to have an opportunity to share experiences on how to live a good quality life outside of their diagnosis (Pillai & Verghese, 2009). Lastly, these activities can create a sense of togetherness with the other residents, which can help them feel less anxious about the thought that no one truly understands what they are going through (Ruthirakuhan et al., 2012). When performing the needs assessment, it was determined that two crucial needs needed to be met for the program to succeed. The first need was getting the program implemented. The site mentor at the facility stated that the facility used a similar program to this idea a couple of years ago. However, due to the COVID pandemic and other things, the facility has gotten away from using that program (Amanda Driscoll, personal communication, March 8, 2022). The program was implemented in 2017, the last time the residents' cognitive levels were assessed. Since then, there has been a significant amount of employee turnover at the facility, so most of the employees do not have an understanding of what Allen's Cognitive Level is, and they have defaulted to providing extensive assistance during ADL performance for residents who required cognitive assistance instead of physical assistance. This increased workload has resulted in increased caregiver burden and residential functional decline. The site mentor also said that the facility needs someone to work with the dementia coordinator and the other employees in the dementia unit to tweak, alter, or do whatever is needed to ensure that the things that the residents do daily in those units are individualized to meet the cognitive needs or levels of the residents (Amanda Driscoll, personal communication, March 8, 2022). This program addressed this critical need by assessing the resident's cognitive level, and the scores were tracked with a chart. These scores varied within the unit, and with this program, the needs of the residents can become more individualized, maximizing the resident's occupational performance. Many have created and researched similar programs to the one utilized for this project. One study was conducted by Gitlin et al. (2021). The authors studied the effects of a tailored activity program on individuals with dementia. They found that while the program did not decrease the behaviors exhibited by the participants, it positively impacted caregiver well-being (Gitlin et al., 2021). One shortcoming of this study was that it emphasized the needs of the caregivers compared to the residents, which could correlate to why the caregivers had a more significant outcome. This shortcoming is where this program differs, as it considers the individuals and their caregivers equally through its program's protocols. Hence, the program emphasizes treating everyone individually (Weise et al., 2018). A second study was conducted by Mhler et al. (2020). The authors also studied the effects of a tailored activity program on individuals with dementia. They found that this program can reduce behaviors and positively impact the individual's quality of life. However, they also stated that due to the low significance of the results, people using this program should proceed cautiously (Mhler et al., 2020). One shortcoming of this study is that they could not determine if there was a genuine impact on mental health. This shortcoming is where this program differs as it utilizes a mental health focus to gauge where the individuals are and to see what kind of impact it has. Lastly, one big difference between these programs and the one I am creating is the environment in which the program is implemented. A third study was conducted by Marx et al. (2019). The authors studied the effects of a tailored activity program on individuals with dementia. They found that the individuals who participated in this program had increased activity engagement (Marx et a., 2019). One shortcoming of this program is that there was only one individual with dementia and one caregiver. This program worked with 14 individuals and 15 caregivers, who will help ensure that the results of this program contain accurate data. Gitlin et al. (2021) placed their program in the home environment, Mhler et al. (2020) placed their program in the community, and Marx et al. (2021) placed their program in the home. However, this program is in a skilled nursing facility where the residents live in a locked dementia unit. The employees there are required to undergo monthly dementia training, and the resources created for this program will be accessible to dementia care coordinators to utilize during the monthly training. Theory, Model, and Frame of Reference The occupation-based model that guided this doctoral capstone experience (DCE) is the Occupational Adaptation (OA) model. This model focuses on the interactive process between an individual and their environment and the internal adaptive process that occurs when an individual engages in occupation (Cole & Tufano, 2020). This model guided the program through a thorough assessment of the person, environment, occupational performance, press for mastery, and relative mastery of the patients in the skilled nursing facility. The information gained through the lens of the OA model allowed informed decisions to be made on how occupational therapy and this program can help promote occupational engagement that meets the cognitive needs of the patients at the facility. The frame of reference (FOR) that guided this DCE is Allens Cognitive Levels frame of reference. This frame of reference focuses on the role of habits and routines, the effect of physical and social contexts, and the analysis of activity demand (Cole & Tufano, 2020). Individuals with dementia are given tasks and activities, whether put on by the activities department or the self-care tasks they are expected to perform, that are too difficult for them to perform based on their cognitive level. Therefore, it often results in non-participation in these activities, or the individuals exhibit behaviors due to the frustrations they experience from the difficulty of these tasks. This frame of reference allowed for the necessary adaptations and altered expectations to help individuals succeed in their tasks and occupations. This frame of reference also aligns well with the OA model and the DCE goal of tailoring the activities and occupations the residents participate in to meet their cognitive level. The information gained through the guidance of the OA model and Allens Cognitive Levels FOR will provide an understanding of how occupational therapy and this program can help improve the quality of life and facilitate engagement for patients with dementia at the skilled nursing facility. Design and Implementation Design This program was developed for three main reasons. Primarily, this program was initially created in 2016, the last time residents with a dementia diagnosis had their cognitive level screened. The disruption of COVID and how care was also provided limited compliance to the earlier program. The staff has since become less confident in its use. Also, once COVID became prevalent, the employees started to shy away from using the program, and eventually, the program was no longer in place (Amanda Driscoll, personal communication, March 8, 2022). Lastly, the mental health benefits when a program like this is implemented. Numerous research articles have been published on this subject, and the two mental health diagnoses, anxiety and depression, have been positively impacted by similar programs. For example, regarding depression, Cheng et al. (2012) found that participating in activities associated with this program has been shown to alleviate the symptoms of depression in individuals who have been formally diagnosed with dementia. Regarding anxiety, Sondell et al. (2021) found that the activities associated with this program can alleviate the mood of individuals formally diagnosed with dementia and decrease the risk of anxiety. This program was developed by first assessing the program from the residents' perspective. Doing this ensured that the program contained protocols emphasizing the importance of treating everyone individually (Weise et al., 2018). Next, the ACLS-5, ADM-placemat, and the physical/communication scales of the RTI were used to measure the resident's ability to perform their self-management tasks, their performance in activities provided by the staff, and their social participation during these activities (Mangiaracina et al., 2019). Once the scores were received, a questionnaire was created utilizing the data found by Gibbons et al. (2015) and Smaling et al. (2021). This questionnaire was created to gather data from the employees who worked with the residents in the dementia units, and their responses were then used to create educational handouts to fill in the knowledge gaps. Implementation The program occurred in the first dementia unit. Sixteen residents in this unit have a formal dementia diagnosis. Based on this, a protocol was created where two or three residents would be evaluated every week and seen for a total of ten visits spanning over three weeks. Over these ten visits, goals were set for each visit. For example, the first two visits involved assessing the residents. The second two visits involved identifying meaningful activities for the residents and determining the cues to which they respond best. The final six visits entailed performing activities and ADLs with the residents and having a nurse present to educate them on the best way to maximize the resident's occupational performance. Numerous successes and challenges occurred throughout the implementation phase of this program. Some successes include building relationships with other residents they had not built prior, increased activity engagement, and resident reports of decreased mental health problems. Some of the challenges included staff carryover and overall participation. There were some difficulties in implementing the questionnaire, as well as improving the carry-over from staff to cue residents instead of performing ADLs for them. Project Outcomes When evaluating the outcomes of this project, a pre/post survey was used to evaluate the staff working in the dementia units. Specifically, surveys can be helpful when gathering data regarding caregiver experiences. In fact, there are a variety of surveys pertaining to caregivers who deal with dementia, specifically the PES, GAIN, and PAC (Smaling et al., 2021). A survey was chosen because it is an outcome measure commonly used in research due to three main benefits. Numerous surveys have been created that have allowed researchers to gain a better understanding of the caregivers experiences when caring for individuals with a dementia diagnosis (Smaling et al., 2021). Utilizing a survey as an outcome measure is a feasible option and can collect data from individuals relatively quickly (Regmi et al., 2016). The third benefit of using a survey as an outcome measure is that it is generally effective. Davis et al. (2018) found that when researchers use a pre/post-survey as an outcome measure, the results are often a great indicator of whether or not participants showed improvement in the information they were assessed on. The pre-survey contained questions on the staff's comfortability caring for residents with a dementia diagnosis, the average cognitive assistance given to the residents each day, the average physical assistance given to the residents each day, whether or not they had heard of the Allen's Cognitive Levels, and if they had, then what they knew about it. The questions in the pre-survey were used for two main reasons. These questions allowed for the opportunity to gain some insight into what the staff who worked in the dementia units already knew prior to the implementation phase of the project. This insight was beneficial as it helped determine where the gaps needed to be filled in to maximize the possibility of carryover occurring once this program had been implemented. These questions also helped create the educational handouts that were used in the program as an educational tool again to fill in the gaps in the staff's knowledge. For example, based on the responses from the pre-survey, handouts were created and presented at an in-service to the staff to go over the resident's ACL level, what kind of cognitive/physical assistance the resident would require at the specific ACL level, what abilities were associated with the residents ACL level, and what activities were appropriate for the resident's ACL level to maximize their socialization in activities. The post-survey used the same questions that were used in the pre-survey to help determine how much the staff in the dementia units had learned, as the questions encompassed the whole purpose of the program, and to determine if the staff had comprehended the information. This would be a determining factor in whether or not carryover would occur. Summary This doctoral capstone experience explored using Allen's Cognitive Levels Assessment to determine the cognitive levels of the patients in the first and second dementia units, along with educating the employees at the skilled nursing facility on tailoring the activities and occupations that the residents participate in to help improve the patient's quality of life. To ensure the validity of each resident's Allen's Cognitive Level, I used a variety of cognitive assessments. These assessments included the ACLS5, the ADM-placemat, and the physical and communication portions of the RTI. After performing a needs assessment, it was recognized that there was a need for this program. The staff who worked at the facility were overburdening themselves by providing assistance in areas the residents could perform. This project also focused on educating the employees at the skilled nursing facility on tailoring the activities and occupations that the residents participate in to help improve the patient's quality of life, decrease their mental health problems, and to reduce the behaviors that occur when they are given tasks or activities that are too challenging for their cognitive level. Dementia is a progressive cognitive decline and individuals with this diagnosis experience changes in their cognition, function, and behavior (Duong et al., 2017). These cognitive changes make individuals with dementia more susceptible to various mental health diagnoses, including depression (Bergdahl et a., 2011) and anxiety (Spector et al., 2015). . When evaluating the outcomes of this project, a pre/post survey was used to evaluate the staff working in the dementia units. The outcome portion was an up-anddown process as there was initial difficulty getting staff participation in the pre-survey. However, as the DCE went along and in-services were performed, it increased participation for post-survey completion. The results showed that the staff had increased knowledge of the program and increased implementation of cognitively appropriate cueing. Conclusion When examining this experience as a whole, it is essential to consider sitespecific accomplishments and personal accomplishments. Site-specific accomplishments include ACL level determined for all residents in unit one, ACL level determined for five residents in unit two, and educational in-services performed for each resident following sessions that determined their ACL level, identified meaningful activities, and determined what cues they respond best to. Personal accomplishments include the development of the cognitive program, developing clinical skills when working with individuals with a dementia diagnosis, and overall knowledge growth of the logistics involved with working in a skilled nursing facility. Outside of the accomplishments, it is important to note how the site benefited from the program. In particular, the site benefitted through their staff gaining knowledge of how to care for an individual based on their ACL level. This knowledge resulted in observed decreased caregiver burden within the staff when they appropriately cued the residents and increased socialization/participation in activities among the residents that were cognitively appropriate. In addition, the site also provided comprehensive educational handouts and resident-specific handouts to ensure the best care for each individual. Lastly, it is essential to talk about what could be done in the future to ensure the carryover of this project. Future work on this project would include continued assessing of the residents ACL level, as it had not been done in almost six years, continued inservices to ensure the staff continues with the carryover of the program, increased ACL appropriate activities to maximize engagement and someone on-site who can administer the aforementioned cognitive assessments. References Amanda Driscoll, personal communication, March 8, 2022 Bergdahl, E., Allard, P., & Gustafson, Y. (2011). Depression among the very old with dementia. International Psychogeriatrics, 23(5), 756-63. http://dx.doi.org/10.1017/S1041610210002255 Cheng, S. T., Chow, P. K., Yu, E. C., & Chan, A. C. (2012). Leisure activities alleviate depressive symptoms in nursing home residents with very mild or mild dementia. The American journal of geriatric psychiatry: official journal of the American Association for Geriatric Psychiatry, 20(10), 904908. Cole, M. & Tufano, R. (2020). Applied theories in occupational therapy: A practical approach (2nd Ed.). SLACK Incorporated. Davis, G. C., Baral, R., Strayer, T., & Serrano, E. L. (2018). Using pre- and post-survey instruments in interventions: determining the random response benchmark and its implications for measuring effectiveness. Public health nutrition, 21(6), 1043 1047. https://doi.org/10.1017/S1368980017003639 Duong, S., Patel, T., & Chang, F. (2017). Dementia: What pharmacists need to know. Canadian pharmacists journal : CPJ = Revue des pharmaciens du Canada : RPC, 150(2), 118129. https://doi.org/10.1177/1715163517690745 Gibbons, E., Hewitson, P., Morley, D., Jenkinson, C., & Fitzpatrick, R. (2015). The Outcomes and Experiences Questionnaire: development and validation. Patient related outcome measures, 6, 179189. https://doi.org/10.2147/PROM.S82784 Gitlin, L. N., Marx, K., Piersol, C. V., Hodgson, N. A., Huang, J., Roth, D. L., & Lyketsos, C. (2021). Effects of the tailored activity program (TAP) on dementia- related symptoms, health events and caregiver well-being: A randomized controlled trial. BMC Geriatrics, 21(1), 114. https://doi.org/10.1186/s12877021-02511-4 Laver, K., Dyer, S., Whitehead, C., Clemson, L., & Crotty, M. (2016). Interventions to delay functional decline in people with dementia: a systematic review of systematic reviews. BMJ open, 6(4), e010767. https://doi.org/10.1136/bmjopen2015-010767 Mangiaracina, F., Meiland, F., Kerkhof, Y., Orrell, M., Graff, M., & Dres, R.-M. (2019). Self-management and social participation in community-dwelling people with mild dementia: a review of measuring instruments. International Psychogeriatrics, 31(9), 12671285. https://doi.org/10.1017/S1041610218001709 Marx, K. A., Scott, J. B., Piersol, C. V., & Gitlin, L. N. (2019). Tailored activities to reduce neuropsychiatric behaviors in persons with dementia: Case report. American Journal of Occupational Therapy, 73(2), 7302205160p1 7302205160p9. https://doi.org/10.5014/ajot.2019.029546 Mhler, R., Renom, A., Renom, H., & Meyer, G. (2020). Personally tailored activities for improving psychosocial outcomes for people with dementia in community settings. The Cochrane database of systematic reviews, 8(8), CD010515. https://doi.org/10.1002/14651858.CD010515.pub2 Pillai, J. A., & Verghese, J. (2009). Social networks and their role in preventing dementia. Indian journal of psychiatry, 51 Suppl 1(Suppl1), S22S28. Regmi, P. R., Waithaka, E., Paudyal, A., Simkhada, P., & van Teijlingen, E. (2016). Guide to the design and application of online questionnaire surveys. Nepal journal of epidemiology, 6(4), 640644. https://doi.org/10.3126/nje.v6i4.17258 Ripley Crossing. (2016, December 28). Ripley Crossing The New Direction in Senior Living. Welcome to Ripley Crossing. Retrieved March 21, 2023, from https://ripleycrossing.com Ruthirakuhan, M., Luedke, A. C., Tam, A., Goel, A., Kurji, A., & Garcia, A. (2012). Use of physical and intellectual activities and socialization in the management of cognitive decline of aging and in dementia: a review. Journal of Aging Research, 2012, P1. Smaling, H. J., Joling, K. J., Achterberg, W. P., Francke, A. L., & van der Steen, J. T. (2021). Measuring positive caregiving experiences in family caregivers of nursing home residents: A comparison of the Positive Experiences Scale, Gain in Alzheimer Care INstrument, and Positive Aspects of Caregiving questionnaire. Geriatrics & gerontology international, 21(8), 636643. https://doi.org/10.1111/ggi.14210 Sondell, A., Lampinen, J., Conradsson, M., Littbrand, H., Englund, U., Nilsson, I., & Lindelf, N. (2021). Experiences of community-dwelling older people with dementia participating in a person-centered multidimensional interdisciplinary rehabilitation program. Bmc Geriatrics, 21(1). https://doi.org/10.1186/s12877021-02282-y Spector, A., Charlesworth, G., King, M., Lattimer, M., Sadek, S., Marston, L., Rehill, A., Hoe, J., Qazi, A., Knapp, M., & Orrell, M. (2015). Cognitive-behavioural therapy for anxiety in dementia: pilot randomised controlled trial. The British journal of psychiatry: the journal of mental science, 206(6), 509516. https://doi.org/10.1192/bjp.bp.113.140087 Weise, L., Jakob, E., Tpfer Nils Frithjof, & Wilz, G. (2018). Study protocol: individualized music for people with dementia - improvement of quality of life and social participation for people with dementia in institutional care. Bmc Geriatrics, 18(1), 18. https://doi.org/10.1186/s12877-018-1000-3 DCE Planning Guide Appendix W ee k DCE Stage (orientation, screening/evaluation, implementation, discontinuation, dissemination) Weekly Goal Objectives Tasks Da te co mp lete 1 Orientation -Complete site orientation by the end of the week -Gain comfortability utilizing the ACLS, ADMplacemat, and physical/com munication scales of the RTI -Start treating nondementia residents who are on OT caseload -Research new literature to add to scholarly report -Finalize MOU -Finalize goals for program and overall experience -Research possible outcome assessment options -Finalize needs assessment 01/ 13/ 23 2 Screening/Evaluation/I mplementation -Continue researching new literature for scholarly report -Create the pre-survey portion of outcome assessment -Administer chosen assessment tools to 3 residents on unit one -Establish outcome assessment -Establish timeline for how long each resident will stay on caseload, how often they will be seen, etc. -Review outcome assessment with site mentor 01/ 20/ 23 3 Implementation -Administer chosen assessment tools to 2 residents on unit one -Create short/longterm goals that correlate with my program and can be used for documentat ion -Review goals with site mentor for clarity and to deter the possibility of being audited 01/ 27/ 23 4 Implementation -Administer chosen assessment tools to 2 residents on unit one -Send out pre-survey portion of established outcome assessment to the employees who work in unit one -Review data from the presurvey portion of established outcome assessment -Take data and create educational handouts that fill in the knowledge gaps 02/ 03/ 23 5 Implementation -Administer chosen assessment tools to 2 residents in unit one -Discharge one resident from caseload and educate staff on their ACL level, abilities associated with their ACL level, and activities that are cognitively appropriate for their ACL level -Create handout for resident with ACLS informatio n and put it into their binder -Participate in activities with residents on caseload to identify activities that are meaningful to them -Review information handout with site mentor to ensure all necessary information is covered -Review discharge with site mentor to receive feedback on documentatio n 02/ 10/ 23 6 Implementation -Administer chosen assessment tools to 1 resident in unit one -Discharge four residents from caseload and educate staff on their ACL level, abilities associated with their ACL level, -Create handout for resident with ACLS informatio n and put it into their binder -Participate in activities with residents on caseload to identify activities that are -Perform inservice to staff for the residents that were discharged 02/ 17/ 23 and activities that are cognitively appropriate for their ACL level meaningful to them 7 Implementation -Administer chosen assessment tools to 1 resident in unit one -Discharge two residents from caseload and educate staff on their ACL level, abilities associated with their ACL level, and activities that are cognitively appropriate for their ACL level -Create handout for resident with ACLS informatio n and put it into their binder -Participate in activities with residents on caseload to identify activities that are meaningful to them -Perform inservice to staff for the residents that were discharged -Review midterm evaluation with site mentor to ensure I am still on track to achieve my goals 02/ 24/ 23 8 Implementation -Administer chosen assessment tools to three resident in unit one -Discharge two residents from caseload and educate staff on their ACL level, abilities associated with their ACL level, and activities that are cognitively appropriate -Create handout for resident with ACLS informatio n and put it into their binder -Participate in activities with residents on caseload to identify activities that are meaningful to them -Work with the -Perform inservice to staff for the residents that were discharged 03/ 03/ 23 for their ACL level activities coordinator on unit one and create activities for the residents on the unit 9 Implementation -Discharge two residents from caseload and educate staff on their ACL level, abilities associated with their ACL level, and activities that are cognitively appropriate for their ACL level -Create handout for resident with ACLS informatio n and put it into their binder -Participate in activities with residents on caseload to identify activities that are meaningful to them -Perform inservice to staff for the residents that were discharged -Start identifying residents on unit 2 for evaluation -Send out post-survey outcome assessment to gather data from staff who work on unit one 03/ 10/ 23 1 0 Implementation -Administer chosen assessment tools to three residents in unit two -Participate in activities with residents on caseload to identify activities that are meaningful to them -Gather data from the postsurvey outcome assessment 03/ 17/ 23 1 1 Implementation -Discharge three residents from caseload and educate staff on their ACL level, abilities associated with their ACL level, and activities that are cognitively appropriate for their ACL level -Create handout for resident with ACLS informatio n and put it into their binder -Participate in activities with residents on caseload to identify activities that are meaningful to them -Perform inservice to staff for the residents that were discharged -Review dissemination plan with site mentor and schedule dissemination date 03/ 24/ 23 1 2 Implementation -Administer chosen assessment tools to two residents in unit two -Discharge three residents from caseload and educate staff on their ACL level, abilities associated with their ACL level, and activities that are cognitively appropriate for their ACL level - Create handout for resident with ACLS informatio n and put it into their binder Participate in activities with residents on caseload to identify activities that are meaningful to them - Perform inservice to staff for the residents that were discharged -Work on developing dissemination presentation 03/ 31/ 23 1 3 Implementation -Continue treating residents on caseload. -Participate in activities with residents on caseload to identify activities that are meaningful to them -Review dissemination plan with site mentor 04/ 07/ 23 1 4 Discontinuation -Discharge two residents from caseload and educate staff on their ACL level, abilities associated with their ACL level, and activities that are cognitively appropriate for their ACL level -Create handout for resident with ACLS informatio n and put it into their binder -Disseminate to stakeholders 04/ 14/ 23  ...

... PROMOTING HOLISTIC CARE THROUGH OT 1 PROMOTING HOLISTIC CARE THROUGH OCCUPATIONAL THERAPY IN THE HIGHRISK MATERNITY TOWER Olivia Voss April 24, 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Jenna Trost, MOT, OTR Mika Mattocks, OTD, OTR PROMOTING HOLISTIC CARE THROUGH OT 2 TABLE OF CONTENTS ABSTRACT................................................................................................................................ 3 CHAPTER I. INTRODUCTION.......................................................................................................... 4 II. BACKGROUND............................................................................................................ 5 III. THEORY........................................................................................................................ 8 IV. PROJECT DESIGN & IMPLEMENTATION............................................................... 9 V. PROJECT OUTCOMES................................................................................................ 10 VI. SUMMARY................................................................................................................... 12 VII. CONCLUSION.............................................................................................................. 13 REFERENCES.......................................................................................................................... 14 TABLES.................................................................................................................................... 16 FIGURES................................................................................................................................... 17 APPENDIX................................................................................................................................ 18 PROMOTING HOLISTIC CARE THROUGH OT 3 ABSTRACT High-risk pregnancy is a growing concern in the United States resulting in complications in both the mother and the fetus. At IU Health Riley Hospital, the maternity tower was built in 2022, to provide medical care to patients with high-risk pregnancies, staffing maternal fetal medicine (MFM) doctors, obstetric certified registered nurses, occupational therapists, physical therapists, social work, and more, to help provide the highest-grade medical care possible. Nurses in the maternity tower stated that most patients struggle with their mental health, during their prolonged hospital admissions. Currently, occupational therapists are treating antepartum patients with limited research backing their interventions. A survey was given to a total of 14 patients, resulting in 14/14 patients feeling worried, anxious, or on edge and having trouble finding activities meaningful to them. The purpose of this project is to identify a patients needs through the lens of occupational therapy, providing an intervention binder to help guide sessions, and creating a handout for carpal tunnel syndrome, following a patient case study. PROMOTING HOLISTIC CARE THROUGH OT 4 INTRODUCTION Approximately 6 million pregnancies occur each year in the United States (Data & Statistics- Reproductive Health, 2021). High-risk pregnancies are prevalent and a growing concern that can lead to extended hospital stays. The identification of a high-risk pregnancy along with prolonged hospitalization may introduce additional maternal anxiety or depressive symptoms due to anticipation and unknowingness of the future. I worked alongside healthcare professionals at IU Health Riley Hospital to create and implement mental health interventions for high-risk pregnant patients. While Riley Hospitals focus is on pediatric care, the hospital added on a new maternity tower to offer a full spectrum of family-centered services. Currently, there is only one mental health assessment currently given to patients upon admission, the Edinburgh Postnatal Depression Scale, which determines the need for additional mental health counseling via perinatal mood therapists. Currently, there are limited mental health resources and interventions being provided to high-risk ante patients. Occupational therapists (OTs) are trained and educated to provide treatment for patients with mental health; it is within their practice through the holistic approach. The goal for my project is to gather mental health data of patients through a questionnaire at the beginning of admission, which contains questions adapted from various mental health screenings. I created a packet including cognitive behavioral therapy resources and mental health intervention handouts for occupational therapists to use and give to patients to decrease the overall anxiety and depression of the prolonged admission. I also completed a case study on a patient who did not have mental health concerns either in the antepartum or postpartum but experienced exacerbated carpal tunnel symptoms during the antepartum and postpartum periods. PROMOTING HOLISTIC CARE THROUGH OT 5 BACKGROUND As a group, anxiety-related disorders are the most common of all psychiatric conditions (Fairbrother et al., 2017). Concerning pregnancy, Fairbrother et al., (2017) found that anxiety or depression onset in pregnancy was five to seven times greater for women experiencing a medically moderate or high-risk pregnancy compared with women experiencing a medically low-risk pregnancy. Anxiety, depression, and other stressful emotions can be harmful to both the mother and the unborn baby. While high-risk patients have access to psychiatric professionals within the hospital setting, the consultation referral rates are very small at about 0.3% (Byatt et al., 2014). Specifically, at Riley Hospital, the only assessment given to patients upon arrival is the Edinburgh Postnatal Depression Screening. If a patient scores high enough, they are referred to a perinatal mental health therapist who then consults on their case. Women struggle as they endure managing different emotions, managing other health issues, appraising others, and worrying about how they are perceived in the hospital (Satyanarayana et al., 2011). This can lead to amplified distress and contribute to women's emotional exhaustion, sense of being overwhelmed, and stress burden. Rileys occupational therapist in the maternity tower stated that the mothers on the high-risk unit are at risk for anxiety and depression because 1) they are a high-risk pregnancy, 2) all sense of meaning is lost, 3) they no longer can participate in meaningful occupations that once ruled their life (K. Salter, personal communication, March 2, 2022). It was also found that women were scared about the potential outcomes of their pregnancies and often overwhelmed in their attempts to cope with their emotions (McCoyd et al., 2020). While these women are trying to avoid stress and overcome their emotions, they are failing to do so with limited interventions and a lack of provided resources (McCoyd et al., PROMOTING HOLISTIC CARE THROUGH OT 6 2020). At Riley, social workers can provide support for patients and families, however, do not fully address anxiety or depression. Bereavement is also a mental health resource, but only in the case of an infant loss. Maternal psychological and social stress during pregnancy can adversely affect the pregnancy outcome with conditions such as the increased risk of morbidity for the child, lower birth weight, and increased risk for preterm birth. Anxiety during pregnancy has also been found to be a strong predictor of postnatal depression (Fairbrother et al., 2017). Maternal stress during pregnancy is more than twice as common among women who gave birth preterm compared to women who gave birth at term (Lilliecreutz et al., 2016). Postpartum maternal anxiety has been associated with impaired adaptability, negative mood, and soothing difficulty in the infant (Fairbrother et al., 2017). A study completed by Yeager, (2016), further investigated relaxation techniques used for antepartum mothers on hospital bedrest, and the results showed improvements in physical wellbeing and sleep, and positively influenced the occupational well-being of this population. Relaxation interventions have resulted in prolonged gestation and positive labor outcomes and improved sleep during pregnancy (Yeager, 2016). Another study explored the benefits of integrative relaxation techniques as they are known to decrease depression, anxiety, and pain in clinical situations and may be beneficial for women hospitalized due to pregnancy (Schlegel et al., 2016). While these studies give data for mental health interventions, the carry-out in the hospitals is not addressed. There is limited data on hospitals utilizing occupational therapy to address the mental health of antepartum patients. Occupational therapists are trained in a holistic approach that takes into consideration the whole person, by being aware that both body and mind need to be considered (Occupational PROMOTING HOLISTIC CARE THROUGH OT 7 Therapy Practice Framework: Domain and ProcessFourth Edition, 2020). The referrals for occupational therapy are beginning to increase as the doctors are understanding the anxiety of the unknown and the effects of prolonged hospitalization. At Riley, occupational therapists receive referrals for prolonged admission (i.e., if they are here 2+ days). Residents decide if a patient would benefit from therapy, however, often consults with therapists at rounds to gain further insight. More patients are beginning to receive referrals due to the increase in occupational deprivation and increase of mental health worries. OTs currently assess a patients independence with ADLs and functional mobility, and while also providing leisure exploration activities and coping mechanisms. Nurses who work in the high-risk unit at Riley were given a one-question survey (see Appendix A) about the occupational needs of their antepartum patients. 10/10 nurses answered their patients would benefit most from mental health interventions during hospitalization. One nurse stated oh definitely something related to mental health, every patient I have treated experiences anxiety while admitted (Cori, personal communication, January 26, 2023). This project provides data as to why patients should receive occupational therapy referrals, while also providing holistic interventions for OTs to utilize to help support the patients as much as possible. Other health concerns, including musculoskeletal injuries, can be overlooked by doctors but would be addressed by an OT because they look at the whole person during the initial evaluation. This project will not only show how occupational therapy can be beneficial for antepartum and postpartum patients, but how to view all aspects of the patients well-being. PROMOTING HOLISTIC CARE THROUGH OT 8 THEORY The Person-Environment-Occupation-Performance (PEOP) is a comprehensive analysis of the whole system contributing to occupational participation (Cole & Tufano, 2008). Information was gained through the lens of the PEOP model to ensure the maximization of occupational performance through intrinsic, extrinsic, and occupations during prolonged hospitalization. This model is centered on the individual and demonstrates how participation in occupation can be impacted by both the individual and the environment. Services provided to antepartum patients focus on their individual needs, their unique environments, and the occupations they need and want to perform. The cognitive behavioral frame of reference emphasizes five aspects of life experience: thoughts, behaviors, emotion/mood, physiological responses, and the environment (Fenn & Byrne, 2013). These aspects are interrelated, meaning that changes in one factor can lead to improvement or deterioration in another (Cole & Tufano, 2008). When dealing with motivation and emotions, this frame of reference can restore functionality in daily activities. Antepartum patients often encounter a variety of different emotions due to the nature of their health state. CBT works to modify a persons thoughts through reinforcement to increase positive behaviors and activities. Interventions are used to encourage social support, talking through difficulties and other activities to decrease negative thoughts and increase positive behaviors (Fenn & Byrne, 2013). Its referenced as a cycle: thoughts create feelings, feelings create behaviors, behaviors reinforce thoughts. This FOR aligns with the PEOP model by showing how extrinsic (hospital) and intrinsic (anxiety) factors affect a persons occupational performance and integrate strategies to improve occupational performance (see Figure 1). PROMOTING HOLISTIC CARE THROUGH OT 9 PROJECT Project Design This project was created because maternal health is an emerging area in occupational therapy, but there are many different types of maternal health. Specifically, in hospitals, there is the problem of delineating a difference between patients who would benefit from social workers, psychologists, or occupational therapists to treat the mental health of patients. The intent of this project is for professionals will understand how OT can be a holistic approach to treating the physical, mental, and emotional well-being of the patient during prolonged hospitalization. When a patient is admitted to the hospital, not only does the environment change but also their individual needs and occupations. There are limited interventions and resources given to patients, even though they are 1) considered a high-risk pregnancy and 2) detached from their usual daily routines and life. A packet of mental health mediations was created, to help the patient have a sense of meaning, outside of being the patient. Resources included in the packet were a daily mood tracker, daily habit tracker, and journal entries that can help guide cognitive behavioral therapy, individually and with an occupational therapist. An additional list of OT interventions was given to IU Health for occupational therapists to utilize with antepartum patients. Project Implementation The purpose of the project was explained to patients prior to participating in the project. If the patient agreed, they were given a pre-survey, containing twelve questions about their mental health over the past seven days and then given again right before, or right after delivery (see Appendix B.1). Inclusion criteria included all new patient referrals, to fill out the initial survey. While some patients are admitted until delivery, the length of stay varies between 1 week PROMOTING HOLISTIC CARE THROUGH OT 10 to 8 weeks. The census of the maternity population varies daily, so it was difficult to ensure patients filled out both the pre- and post-survey. Data analysis includes 2 different categories: patients filling out only pre-survey and patients who completed both surveys with the mental health packet. The data collected allows professionals to understand the need for mental health interventions and promoting healthy well beings through the occupational therapy lens. OUTCOMES The survey given to participants included statements adapted from different mental health assessments, including Edinburgh Post Natal Screening (Levis et al., 2020), Antenatal (Psychosocial) Risk Questionnaire (Ruyak & Qaedan, 2018), and Becks Anxiety Inventory (Beck et al., 1988). The survey was given to 14 participants, at the beginning of their prolonged hospitalization. The survey included eight statements rating the amount of anxiety participants felt being hospitalized and rating their overall emotions (Table 1A), and four questions regarding their positive well-being self (Table 1B). Data analysis of the returned surveys was completed via quasi-experimental qualitative statistics. Out of the first 8 statements, most participants agreed and chose yes, all of the time or yes, most of the time on two statements. These statements were: I have felt worried, anxious, or on edge, I have had trouble relaxing or finding something to do, and I have blamed myself unnecessarily when things went wrong. Mental Health Treatment Sessions Each participant received one on one sessions with an occupational therapist at least one time a week. Treatment sessions were based on cognitive behavioral theory and talk therapy, allowing the patient to choose what they felt was most important to them that week. It was noted that most participants chose to talk about their past week, the struggles they encountered, and the questions they had about delivery or postpartum. Other sessions included activities to help PROMOTING HOLISTIC CARE THROUGH OT 11 decrease depression that may arise with prolonged hospitalization, including a countdown chain to mark the days until delivery. Additionally, patients were provided education about the Caesarian delivery process and a NICU tour, to further decrease the anxiety leading up to their delivery date. Sessions lasted 20-30 minutes at a time, with participants verbalizing decreased anxiety and stress at the end of the session. Physical Health Treatment Sessions Participants also received assistance with functional mobility and activities of daily living (ADLs), if their endurance or activity tolerance was noted to be decreased. There were three participants that did not demonstrate mental health or functional mobility deficits but experienced exacerbated symptoms secondary to carpal tunnel or increased edema in their upper extremities (UE). Therapists were able to contact the resident to get a referral for prefabricated wrist splints or OP therapy at discharge. Therapists provided informal education regarding splint wear schedules, exercises to help decrease the pain and numbness felt in the patients UE, positioning for postpartum and caring for the baby, and ways to reduce repetitive movements that may exacerbate symptoms. A case study (Appendix C) was performed on one patient, to further educate professionals on how OT is beneficial for patients with carpal tunnel, resulting in creating a carpal tunnel syndrome educational handout (Appendix D), to provide to patients. Mental Health Interventions Binder Further, a binder of mental health interventions (Appendix E) was composed of in-depth evidence-based research, regarding occupational therapy interventions to help guide treatment sessions beyond talk therapy. PROMOTING HOLISTIC CARE THROUGH OT 12 SUMMARY Being admitted to a high-risk antepartum unit has the potential to negatively impact the expectant mother and her participation in her daily routines and favorite activities. A review of the literature revealed that patients who are admitted for a prolonged period often demonstrate poor mental health, including anxiety and depression. Results of the questionnaire given to patients revealed poor mental status including feelings of anxiety, worry, boredom, and selfblame. Patients can also face physical needs, including limited mobility and upper extremity disorders (i.e., Carpal Tunnel). All these needs could be met by an occupational therapist providing therapeutic interventions and holistic care to promote health and wellness and prevent disability in both the mother and the developing fetus. A binder of interventions was developed with the intent of assisting occupational therapists providing services to high-risk expectant women. Therapeutic interventions were researched in the areas of stress management and coping skills, exercise, and emotional health. Preparatory, purposeful, and occupation-based interventions enable occupational therapists to facilitate individual sessions for the benefit of expectant women during their high-risk pregnancies. PROMOTING HOLISTIC CARE THROUGH OT 13 CONCLUSION Completing the DCE project at IU Health Riley was an exciting learning opportunity, including program development and learning advanced clinical skills in an emerging practice area (maternity). Professionalism and clinical skills were gained, through talking with interprofessional disciplinaries including RNs, PTs, case managers, social work and MFM residents. The project overall serves to increase the number of referrals in the maternal population admitted for prolonged hospitalization, and to provide mental health activities and interventions for occupational therapists. The intent of this project was to increase the mental health of patients who are admitted for prolonged hospitalization through evidence based researched interventions. Future implications include completing further questionnaires to RNs and patient surveys, to ensure the patients mental health is improving. Implications for occupational therapy as a profession include research behind occupational therapists treating the maternal population, and interventions specific to this population. PROMOTING HOLISTIC CARE THROUGH OT 14 REFERENCES Beck, A. T., Epstein, N., Brown, G., & Steer, R. (1988). Beck Anxiety Inventory [Database record]. APA PsycTests. Byatt, N., Hicks-Courant, K., Davidson, A., Levesque, R., Mick, E., Allison, J., & Moore Simas, T. A. (2014). Depression and anxiety among high-risk obstetric inpatients. General Hospital Psychiatry, 36(6), 644649. https://doi.org/10.1016/j.genhosppsych.2014.07.011 Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, N.J.: SLACK Inc. Conceio, R. M. da, Brito, J. S. de, Silva, E. V. da, & Marcelino, J. F. de Q. (2020). Occupational therapy practice in a high-risk obstetric center. Cadernos Brasileiros de Terapia Ocupacional, 28(1), 111126. https://doi.org/10.4322/2526-8910.ctoAO1927 Data & Statistics- Reproductive Health. (2021). Retrieved 30 March 2022, from https://www.cdc.gov/reproductivehealth/data_stats/index.htm Fairbrother, N., Young, A., Zhang, A., Janssen, P., & Antony, M. (2017). The prevalence and incidence of perinatal anxiety disorders among women experiencing a medically complicated pregnancy. Archives of Womens Mental Health, 20(2), 311319. Fenn, K., & Byrne, M. (2013). The key principles of cognitive behavioral therapy. InnovAiT, 6(9), 579585. https://doi.org/10.1177/1755738012471029 Gourounti, C., Karpathiotaki, N., & Vaslamatzis, G. (2015). Psychosocial stress in high risk pregnancy. International Archives of Medicine. https://doi.org/10.3823/1694 Kingston, D., Janes-Kelley, S., Tyrrell, J., Clark, L., Hamza, D., Holmes, P., Parkes, C., Moyo, N., McDonald, S., & Austin, M.-P. (2015). An Integrated Web-Based Mental Health Intervention of Assessment-Referral-Care to Reduce Stress, Anxiety, and Depression in Hospitalized Pregnant PROMOTING HOLISTIC CARE THROUGH OT 15 Women with Medically High-Risk Pregnancies: A Feasibility Study Protocol of Hospital-Based Implementation. JMIR Research Protocols, 4(1). https://doi.org/10.2196/resprot.4037 Levis, B., Negeri, Z., Sun, Y., Benedetti, A., & Thombs, B. (2020). Accuracy of the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression among pregnant and postpartum women: systematic review and meta-analysis of individual participant data. BMJ 2020, 371. Lilliecreutz, C., Larn, J., Sydsj, G., & Josefsson, A. (2016). Effect of maternal stress during pregnancy on the risk for preterm birth. BMC Pregnancy and Childbirth, 16(1), 5. https://doi.org/10.1186/s12884-015-0775-x Louis-Jacques, A. F., Vamos, C., Torres, J., Dean, K., Hume, E., Obure, R., & Wilson, R. (2020). Bored, isolated, and anxious: Experiences of prolonged hospitalization during high-risk pregnancy and preferences for improving care [Preprint]. Obstetrics and Gynecology. https://doi.org/10.1101/2020.12.11.20247239 McCoyd, J. L. M., Curran, L., & Munch, S. (2020). They say, "If You Don't RelaxYou're Going to Make Something Bad Happen": Women's Emotion Management During Medically High-Risk Pregnancy. Psychology of Women Quarterly, 44(1), 117129. https://doi.org/10.1177/0361684319883199 Occupational therapy practice framework: domain and processfourth edition. (2020). The American Journal of Occupational Therapy, 74(Supplement_2), 1-87. https://doi.org/10.5014/ajot.2020.74S2001 Rubarth, L. B., Schoening, A. M., Cosimano, A., & Sandhurst, H. (2012). Womens Experience of Hospitalized Bed Rest During HighRisk Pregnancy. Journal of Obstetric, Gynecologic & Neonatal Nursing, 41(3), 398407. https://doi.org/10.1111/j.1552-6909.2012.01349.x PROMOTING HOLISTIC CARE THROUGH OT 16 Ruyak, S. L., & Qeadan, F. (2018). Use of the Antenatal Risk Questionnaire to Assess Psychosocial Risk Factors Associated with Risk for Postpartum Depression: A Pilot Study. Journal of midwifery & women's health, 10.1111/jmwh.12873. Advance online publication. https://doi.org/10.1111/jmwh.12873 Satyanarayana, V. A., Lukose, A., & Srinivasan, K. (2011). Maternal mental health in pregnancy and child behavior. Indian Journal of Psychiatry, 53(4), 351361. Schlegel, M. L., Whalen, J. L., & Williamsen, P. M. (2016). Integrative Therapies for Women with a High-Risk Pregnancy During Antepartum Hospitalization. MCN. The American Journal of Maternal Child Nursing, 41(6), 356362. https://doi.org/10.1097/NMC.0000000000000279 Smorti, M., Ginobbi, F., Simoncini, T., Pancetti, F., Carducci, A., Mauri, G., & Gemignani, A. (2021). Anxiety and depression in women hospitalized due to high-risk pregnancy: An integrative quantitative and qualitative study. Current Psychology. https://doi.org/10.1007/s12144-021-01902-5 Van Ravesteyn, L. M., Lambregtse - van den Berg, M. P., Hoogendijk, W. J. G., & Kamperman, A. M. (2017). Interventions to treat mental disorders during pregnancy: A systematic review and multiple treatment meta-analysis. PLOS ONE, 12(3). https://doi.org/10.1371/journal.pone.0173397 Yeager, J. (2019). Relaxation Interventions for Antepartum Mothers on Hospitalized Bedrest. The American Journal of Occupational Therapy, 73(1), 1-7. https://doi.org/10.5014/ajot.2019.025692 PROMOTING HOLISTIC CARE THROUGH OT 17 TABLE 1A Statements regarding the amount of anxiety patients felt being hospitalized and their overall emotions Statement Yes, quite a lot 9 Yes, sometimes 4 No, not much 1 No, never I have had trouble relaxing or finding something to do 6 6 1 1 I have blamed myself unnecessarily when things went wrong 1 7 6 I have been so upset, that I have had difficulty sleeping 3 9 2 Things have been getting on top of me 4 9 1 3 5 5 6 8 1 2 12 Yes, sometimes 4 No, not much No, never I have looked forward with enjoyment to things Yes, quite a lot 10 I feel like I have a sense of worth, while hospitalized 11 3 Thinking about anxiety, I feel prepared to give birth 4 6 4 I feel equipped with my coping skills 5 8 1 I have felt worried, anxious or on edge I have questions that I have not received answers to 1 I have felt scared or panicky with no assistance from medical professionals I feel I have no support from medical professionals during this hospitalization TABLE 1B Statements regarding their positive well-being self Statement PROMOTING HOLISTIC CARE THROUGH OT FIGURE 1 18 PROMOTING HOLISTIC CARE THROUGH OT APPENDIX A What type of occupational therapy interventions would your ante patients most benefit from? Assistance with ADLs (Showering, bathing, functional mobility) Mental health interventions Receiving adaptive equipment to assist patients with ADLs (shower chair, BSC) 19 PROMOTING HOLISTIC CARE THROUGH OT 20 APPENDIX B.1 The antenatal mental health survey that was given to patients pre- and post-project implementation. I have looked forward with enjoyment to things a) Yes, quite a lot b) Yes, sometimes c) No, not much d) No, not at all I feel equipped with my coping skills I have felt worried, anxious or on edge e) Yes, quite a lot f) Yes, sometimes g) No, not much h) No, not at all I have questions that I have not received answers to a) Yes, quite a lot b) Yes, sometimes c) No, not much d) No, not at all I have had trouble relaxing or finding something to do a) Yes, quite a lot b) Yes, sometimes c) No, not much d) No, not at all I have felt scared or panicky with no assistance from medical professionals a) Yes, quite a lot b) Yes, sometimes c) No, not much d) No, not at all I have blamed myself unnecessarily when things went wrong a) Yes, most of the time b) Yes, some of the time c) Not very often d) No, never I feel like I have a sense of worth, while hospitalized a) Yes, quite a lot b) Yes, sometimes c) No, not much d) No, not at all I have been so upset, that I have had difficulty sleeping a) Yes, quite a lot b) Yes, sometimes c) No, not much d) No, not at all Thinking about anxiety, I feel prepared to give birth a) Yes, quite a lot b) Yes, sometimes c) No, not much d) No, not at all Things have been getting on top of me a) Yes, quite a lot b) Yes, sometimes c) No, not much d) No, not at all I feel I have no support from medical professionals during this hospitalization a) Yes, quite a lot b) Yes, sometimes c) No, not much d) No, not at all a) b) c) d) Yes, quite a lot Yes, sometimes No, not much No, not at all PROMOTING HOLISTIC CARE THROUGH OT 21 APPENDIX C Carpal tunnel syndrome case study Introduction: AB is a 30-year-old female, G3P2012 presenting after routine Caesarian delivery. Pregnancy complicated by obesity, chronic hypertension, previous Caesarian delivery x1, and mild asthma. Delivery was uncomplicated. AB was routinely referred to only physical therapy for a safe discharge plan to home. AB complains of increased bilateral edema, pain and numbness and tingling in bilateral hands (primarily digits 1, 2, & 3) that travels up forearm and arm all the to the shoulder. AB was diagnosed with carpal tunnel syndrome in 2017 and was given wrist cock up splints to alleviate the pain. She states the symptoms increased, thus she deferred wear at the time. AB is a painter and gardener by trade, of which requires repetitive movements of the wrist. Symptoms have waxed and waned since diagnosis. She noticed increased pain, numbness, and weakness in 3rd month of pregnancy and complains mostly about decreased hand strength and fine motor skills. Upon delivery, she noticed her hands, wrists, and forearms to be edematous limiting function. As a mother with a newborn, she has many movements that are repetitive when caring for baby including breast pumping, breast feeding, changing diapers, while still caring for another toddler at home. Recommendations and implementation plan: This occupational therapist completed chart review and met with the patient on post-op day 2, where she complained of the symptoms and was worried about her ability to care for baby and other child at home. This therapist supplied her with bilateral prefabricated wrist cock up splints to help decrease the symptoms she is feeling. Education was provided to AB to ice and rest as able, delegating care for baby to friends and family as able, as well asking doctors about medication for pain management. This therapist also provided AB with an outpatient OT referral if symptoms do not subside with splint wear and rest. Alternatives and decision criteria: Occupational therapy can provide different treatment options for patients with carpal tunnel syndrome. Because this patient was close to discharge, the therapist deferred providing exercises to the patient due to the inability to ensure patient was completing exercises adequately. Custom splints can be made for patients; however, because of the acuity of exacerbation, it was more realistic for the patient to try prefabricated splints versus custom splints. Furthermore, higher doses of pain medication can be given to the patient to elicit pain management, however AB planned to breastfeed, which could transmit higher pain medication to the newborn, which can affect the newborn negatively. Outpatient OT referral was recommended to the patient, however, was not required due to the circumstances AB was going home with the role of taking care of a newborn and toddler child. Analysis: AB explained her concerns to physical therapy which warranted an occupational therapy evaluation. The evaluation was completed one day prior to AB being discharged home, PROMOTING HOLISTIC CARE THROUGH OT thus limiting the treatment plan for carpal tunnel syndrome. If AB would have been initially evaluated by the occupational therapist, course of treatment may have been different. Exercises could have been given to the patient with assurance of completing them correctly. Further pain management could have been discussed with the doctor to ensure the patient was getting the best treatment course. 22 Conclusion: AB was given proper education and resources to help alleviate pain and numbness and weaknesses that is a result of carpal tunnel syndrome. If occupational therapy was referred initially, treatment course and discharge plans may have been different, resulting in further relief. It also would have been beneficial if the patient was given a handout explaining the disorder with recommendations available to refer to. Though the therapist provided education, we are unable to say whether the patient can remember all information provided, with no handout to refer to. This case study was intended to provide education and data to enable carpal tunnel handouts to be created and given to patients to ensure recommendations are remembered and able to be effectively carried out when returning home. Appendix D PROMOTING HOLISTIC CARE THROUGH OT 23 CARPAL TUNNEL SYNDROME A common disorder that occurs when the median nerve, which passes through the wrist, becomes compressed. What can cause carpal tunnel? Frequent, repetitive movements involving a bent elbow or wrist Increased swelling of hand, wrist, or arm What are the symptoms? This disorder most often affects the thumb, index, and middle fingers. You may feel numbness, tingling, weakness, or pain in your hand and wrist. Your fingers might feel useless, or you might wake up and feel you need to shake out your hand or wrist. Treatment options: Wrist brace + schedule: ___________________ Ice Rest Exercises (see next page for pictures and explanation) Ask your doctor about medication for pain and swelling Changing the way, you position yourself when caring for baby (see pictures on next page for tips) What if my symptoms dont improve? Outpatient occupational therapy (OT) can provide further treatment including positioning, pain management, exercises, custom splinting. Ask your OB or PCP about an outpatient OT referral or call ________________. What can I do to decrease the symptoms after having a baby? Keeping wrist and elbow in natural positioning during rest Avoiding motions that bend the wrist or elbow a lot, when doing self-care and caring for baby Asking for help from others when able Keep the affected arm propped on pillows when not using Using the arm when able, to give the affected arm rest when able PROMOTING HOLISTIC CARE THROUGH OT 24 Exercises (with explanation) to help decrease the symptoms: Complete these exercises 4-5x/day 2 1 3 4 1. All fingers straight, including thumb 2. Bend fingers at bottom knuckles, while keeping the top and middle knuckles straight, thumb straight 3. Bend fingers at the top and middle knuckles, while keeping bottom knuckles straight, thumb straight 4. Bend fingers at the middle and bottom knuckles, while keeping the top knuckles straight 5. Bend all knuckles, including thumb to make a full fist Positions when caring for baby: 5 PROMOTING HOLISTIC CARE THROUGH OT 25 NO When holding baby: keeping wrist straight, small bend in elbow, shoulders relaxed PROMOTING HOLISTIC CARE THROUGH OT When feeding baby: building up pillows to bring baby to you, straight wrist, small bend in elbow, relaxed shoulders 26 PROMOTING HOLISTIC CARE THROUGH OT 27 When breast pumping: holding pumps with fingers away from body, straight wrist, small bend in elbow, relaxed shoulders, LIGHT grip on bottle PROMOTING HOLISTIC CARE THROUGH OT Appendix E MENTAL HEALTH INTERVENTION IDEAS FOR ANTEPARTUM PATIENTS 28 PROMOTING HOLISTIC CARE THROUGH OT 29 Creating a worry box Write down all worries and emphasize closing it, to leave worries behind during stressful situations or when given bad news Starting small and simple rituals that can begin in the hospital and carried out at home Breathing techniques when first waking up or before going to bed A special drink while sitting by a window and reflecting on the positives that happened during that day Learning a lullaby/song to sing to baby in-utero, in NICU, or at home before bed Listening to a poetry podcast 1x/day Filling the room with patients favorite Bible verse, positivity quotes or new parenthood quotes Dive into the internet with the patient, allowing them to take control with help from you as needed Creating a schedule each day with simple tasks that need to be done every day, as well as planned ultrasounds, etc (example on next page) PROMOTING HOLISTIC CARE THROUGH OT SUNDAY 30 daily planner Todays Date: Write your three top goals for today __________________________________________________________________________________________ 6AM: 7AM: 8AM: 9AM: 10AM: 11AM: 12PM: 1PM: 2PM: 3PM: 4PM: 5PM: 6PM: 7PM: 8PM: 9PM: SCHEDULE PROMOTING HOLISTIC CARE THROUGH OT 31 List out new things the patient wants to learn to fill days during prolonged hospitalization (Nillni et al., 2018) - i.e., Crocheting, writing (poems), painting Creating a postpartum plan Managing meal preparation Delegating household chores Delegating childcare (if applicable) Access to community support resources Reviewing Caregiver Education to avoid injury Proper positioning when caring for baby Avoiding repetitive wrist/elbow flexion, tight gripping Asking for help from others Upper body ROM and strengthening exercises to prevent decreased activity tolerance Yoga positions and stretches for mindfulness and movement (on next page) PROMOTING HOLISTIC CARE THROUGH OT c b a d g 32 f e h i j a. Laying on your back, legs up on a wall b. Wide leg squat, toes pointing out c. Ring sit, leaning on one arm, other arm reaches over, leaning to one side d. Cat/cow in quadruped position e. Laying on your back, knees bent, arms straight by side, bridge up f. W position, open hips, leaning forward with both arms straight g. Pillow under one bent leg, other leg straight, leaning forward onto pillow h. Lounge position, one knee in front of the other, reaching up i. Downward dog, both legs straight, leaning over with arms straight j. Deep Squat, pushing legs out with arms PROMOTING HOLISTIC CARE THROUGH OT ** FOCUS ON BREATHING IN THROUGH YOUR NOSE, OUT THROUGH YOUR MOUTH ** HOLD EACH POSITION FOR 15-30 SECONDS Practicing 5 senses to deescalate from stressful situations including bad news from doctors and increased anxiety leading up to delivery (Nillni et al., 2018) 33 PROMOTING HOLISTIC CARE THROUGH OT 34 NICU expectations and general education Who will I see, caring for my baby? Neonatologists These are doctors specially trained in newborn intensive care. Neonatal nurse practitioner This is a registered nurse who has received advanced education and specialized training in neonatal intensive care. Neonatal nurses Neonatal respiratory therapists These nurses have advanced training in newborn intensive care. They work under the supervision of doctors and will likely be the people working most closely with your baby daily. These are members of the NICU team responsible for the therapeutic equipment and processes that help the babies breathe, such as ventilators. Physical and Occupational These health professionals are trained to work with premature Therapists infants on promoting positive touch and assessing possible movement issues. Speech Therapists Other specialists NICU Social Workers These are professionals trained in speech and language problems. They often work with newborns in NICUs to help them with feeding, sucking, and swallowing problems. NICU babies often require treatment from neurologists, cardiologists, pediatric ophthalmologists, or surgeons. These specially trained physicians are consulted to treat specific issues with a newborns brain, heart, or eyes, etc. These professionals are trained to help families cope with the emotional, financial, and logistical aspects of a premature babys NICU stay. Social workers can help with insurance difficulties and assist in making any special arrangements necessary for a babys discharge or follow-up care. PROMOTING HOLISTIC CARE THROUGH OT 35 Common types of equipment seen in the NICU: Feeding tubes. NICU babies often require help feeding because they are not yet able to suck and swallow from a breast or bottle effectively. In these cases, a feeding tube is placed into the babys stomach through the mouth or the nose to deliver feeds. Once a baby can suck, swallow, and breathe at the same time, they can attempt to breastfeed or bottle feed. Isolettes. These are the small beds enclosed by clear, hard plastic in which the babies are placed. The temperature in these beds is controlled and closely monitored They also have windows on port holes, that allow nurses, doctors, and parents access to the babies. Radiant warmers These are open isolette beds that warm babies with heat overhead, allowing easy access for doctors and nurses. Intravenous catheters (IVs). An IV is a thin tube inserted into a vein with a small needle. Almost all babies in the NICU have an IV for administering fluids and medications. In younger babies, IVs may be placed in the babys umbilical cord, hands, arms, feet, legs, or scalp. Monitors Infants in the NICU are attached to monitors, which measure their heart rate, blood pressure, breathing rate, and oxygen saturation in their blood. Phototherapy. Preterm infants sometimes have a high bilirubin level. This results in jaundice, or the yellowish discoloration of the skin and whites of the eyes. Special lights may be attached to a babys isolette to help to lower the bilirubin level in the babys blood. Respiratory assistive devices: NICU babies may need extra help to breathe. There are many kinds of devices, including nasal cannula, CPAP, BiPAP, ventilators, all working together to help deliver the perfect amount of oxygen baby needs. PROMOTING HOLISTIC CARE THROUGH OT Breathing Exercises Medically reviewed by Adithya Cattamanchi, M.D., Pulmonology 36 (Yeager, 2019) PROMOTING HOLISTIC CARE THROUGH OT Breathe OUT 37 Breathe IN Follow the star breathing exercise: Slow breathing, IN through your nose, OUT through your mouth Holding breath IN x3 seconds at black circles PROMOTING HOLISTIC CARE THROUGH OT Visual Imagery Therapist leads the patient 38 Elisha Goldstein, Ph.D. and Stefanie Goldstein Ph.D. Find a private calm space and make yourself comfortable. Take a few slow and deep breaths to center your attention and calm yourself. Close your eyes. Imagine yourself in a beautiful location, where everything is as you would ideally have it. Some people visualize a beach, a mountain, a forest, or a being in a favorite room sitting on a favorite chair. Imagine yourself becoming calm and relaxed. Alternatively, imagine yourself smiling, feeling happy and having a good time. Focus on the different sensory attributes present in your scene so as to make it more vivid in your mind. For instance, if you are imagining the beach, spend some time vividly imagining the warmth of the sun on your skin, the smell of the ocean, and the sound of the waves, wind and seagulls. The more you can invoke your senses, the more vivid the entire image will become. Remain within your scene, touring its various sensory aspects for five to ten minutes or until you feel relaxed. While relaxed, assure yourself that you can return to this place whenever you want or need to relax. Open your eyes again and then rejoin your world. For the patients who have other children at home, expressing sadness due to not be able to see other children: Find a private calm space and make yourself comfortable. Take a few slow and deep breaths to center your attention and calm yourself. Close your eyes. Imagine yourself in your own home, where everything is as you would ideally have it. Some people think back to when their child was a baby, rocking them to sleep in a recliner, or playing outside with all of their children. Imagine yourself becoming calm and relaxed. Alternatively, imagine yourself smiling, feeling happy and having a good time. Focus on the different sensory attributes present in your scene so as to make it more vivid in your mind. The more you can invoke your senses, the more vivid the entire image will become. Remain within your scene, exploring its various sensory aspects for five minutes or until you feel relaxed. While relaxed, assure yourself that you can return to this place whenever you want or need to relax. Open your eyes again and then rejoin your world. PROMOTING HOLISTIC CARE THROUGH OT 39 Guided Imagery 7 Tips for Creating Positive Mental Imagery Traci Stein Ph.D., MPH Therapist leads the patient 1. Decide on the end goal first. 2. With the larger goal in mind, write down each step needed to reach it. Be realistic and descriptive. For example, if the goal is to have a healthy baby and smooth delivery/recovery, create smaller goals to reach the end goal 3. Use multi-sensory imagery (seeing, hearing, sensing, smelling, tasting, as well as the feeling of moving). See yourself successfully in the labor and delivery room, filled with all the people that you love. Imagine the positive sounds you may hear of excitement, joy, newborn cries. Feel your body getting lighter and allow yourself to feel pride, joy, a sense of accomplishment as you lose those unwanted pounds. Hear yourself crying tears of joy. 4. Focus on both the observable changes and the inner changes 5. As you become aware of barriers to your goal, imagine leaving them behind. {I often suggest patients envision allowing ways of coping that no longer serve them to flow out easily with the breath and imagine them as dried leaves or other debris that can blow safely off into the distance.} 6. Use affirming, success-oriented language that is grounded in the present moment rather than in the future. So I am happy, and enjoy exercise and nutritious foods, rather than I will be happy. 7. Record yourself delivering the imagery. Your own voice lovingly encouraging you can be an extremely potent tool for creating change. PROMOTING HOLISTIC CARE THROUGH OT 40 Identifying Emotions Emotions A-Z: Angry Anxious Aware Ashamed Amused Apathetic Aggressive Alienated Annoyed Apathetic Bashful Bewildered Bored Critical Confused Creative Content Cheerful Confident Determined Depressed Discouraged Disgusted Disappointed Daring Delightful Ecstatic Excited Embarrassed Envious Extravagant Exhausted Faithful Furious Foolish Fascinating Frustrated Guilty Helpless Hurt Hostile Humiliated Hysterical Hateful Insecure Innocent Intimate Insignificant Intelligent Inferior Inadequate Joyful Jealous Loving Lonely Mad Miserable Negative Nurturing Optimistic Paranoid Peaceful Powerful Playful Proud Pensive Puzzled Relieved Relaxed Respected Rejected Sad Scared Submissive Sleepy Stimulating Stubborn Satisfied Sure Sentimental Sorry Shocked Serene Stupid Selfish Skeptical Sexy Trusting Thoughtful Thankful Valuable Weak Withdrawn Worthwhile PROMOTING HOLISTIC CARE THROUGH OT 41 Use this list to have patients highlight emotions they are feeling and describe the specific situation as to why they are feeling it Stimulation of Mother-baby bond (Wulff et al., 2021) At 26 weeks, a baby may react to noises both inside and outside the mothers body and may be soothed by the sound of her voice. After 32 weeks, baby can recognize certain words As well as remembering certain sounds from their mothers language, babies may remember certain music played to them in the womb. Ways to promote mother-baby bonding: Talk and sing to your baby, knowing he or she can hear you. Gently touch and rub your belly or massage it. Respond to your babys kicks. In the last trimester, you can gently push against the baby or rub your belly where the kick occurred and see if there is a response. Play relaxing and calming music to your baby. Music that mimics a heartbeat of around 60 beats per minute, such as lullabies, is useful. Activity: Create a Pregnancy Memoir (Wulff et al., 2021) Explain to the mothers(s) that the pregnancy experience is often forgotten once the baby is born. Creating a memoir of the pregnancy through letters, poems, or a book is one way to bond with the unborn baby and a way to remember the experience for years to come. Discuss possible poem and book titles. Possible Titles: 1. When You Were Inside Me 2. The Day I Found Out About You 3. My Baby 4. My Pregnancy 5. You&Me 6. My Pregnancy Experience ASK: How does it feel to express your emotions to your baby? What feelings do you have about sharing what you have written? PROMOTING HOLISTIC CARE THROUGH OT Pain management (beyond medication) Deep breathing techniques Stretches for head, neck, back Repositioning throughout day Walking around unit Hot showers (if indicated) Massage 42 (Yeager, 2019) (Yeager, 2019) Identify where the pain is and factors that may lead to the cause (positioning, stress, tension, posture) WHAT IS ON THE NEXT FEW PAGES: WORKSHEETS FOR PATIENTS TO COMPLETE ON THEIR OWN - Journal prompt ideas - Habit tracker for completing ADLs - Letter to future self - Place to write questions for medical professionals habit tracker PROMOTING HOLISTIC CARE THROUGH OT 43 journaling hydrate hallway walk breakfast lunch dinner watch tv read music PROMOTING HOLISTIC CARE THROUGH OT 44 daily activities to make me feel BETTER BRUSH MY TEETH TAKE A SHOWER WALK IN THE HALLWAY DO SOMETHING I LOVE WEAR MY OWN CLOTHES TALK TO A LOVED ONE SIT IN THE CHAIR Q & A PROMOTING HOLISTIC CARE THROUGH OT WHAT DO I WANT TO 45 KNOW? PROMOTING HOLISTIC CARE THROUGH OT 46 future LETTER TO: mama ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ PROMOTING HOLISTIC CARE THROUGH OT 47 ________________________________________________ ________________________________________________ IDEAS Daily thoughts Daily worries How do I rest Something good that has happened this week Fears you have overcome I am thankful for Things you want to learn Goals for my future PROMOTING HOLISTIC CARE THROUGH OT What kind of mama do I want to be? Letter to my role model How do I deal with sadness? New coping strategies I want to try Appendix F: Doctoral Capstone Experience and Project Weekly Planning Guide 48 PROMOTING HOLISTIC CARE THROUGH OT Week 1 DCE Stage (orientation, screening/evaluation, implementation, discontinuation, dissemination) Orientation Weekly Goal - - 2 Screening/Evaluation - - 3 Screening/ Evaluation - - 4 Implementation - Introduce self to the rehab team and explain my project. Get ready to implement project Orient to Maternity Tower and Simon Family Tower Self-aware of evidenced based practice and literature review Find top 2 mental health assessments for pre/post data Get ready to implement project Lead evaluation and treatments for simple cases Meet with ante nurses with Mika to inform of project and project plans Complete intro and background drafts Gather all nurse data for needs assessment 49 Objectives Tasks Needs assessment completed Finalize MOU Work with CI to go over timeline. Meet with OT/PT in maternity unit Learn charting system/write notes Search EBP and literature about personnel are vital to the highrisk antes Pros/cons to each mental health assessments relevant to antepartum Write up evaluation and treatment notes (2-3 day) Write up nurse questionnaire to gain information for needs assessment Create/adapt questionnaire for ante patients Set up meetings with nurses, PT, residents, social work Date complet 1.11.23 1.20.23 Search mental health assessments relevant to antepartum Finalize intro 1.27.23 Begin writing background Continue gaining rapport with nurses Search possible mental health 2.3.23 PROMOTING HOLISTIC CARE THROUGH OT - 5 Implementation - - 6 Implementation - 7 Implementation - 8 Implementation - Begin giving ante patients questionnaire 50 Figure out plan for population (who will receive the questionnaire versus the interventions) At least 5 patients to fill out questionnaire Give MH resources to appropriate patients Begin binder of intervention resources Figure out what an appropriate patient looks like At least 5 patients to fill out questionnaire Weekly check ins with patients Add 2 resources to intervention binder At least 3 patients to fill out questionnaire Weekly check ins with patients Add 2 resources to intervention binder At least 2 patients to fill out questionnaire Weekly check ins with patients Create carpal tunnel handout draft Discuss pts progress with CI, RN, resident assessments for hospitalized patients Continue searching EBP Discuss with CI about possible patients 2.11.23 Go to rounds Discuss pts progress with CI, RN, resident Discuss pts progress with CI, RN, resident EBP on carpal tunnel in postpartum Go to rounds 2.17.23 EBP on MH inteventions Go to rounds 2.25.23 EBP on MH inteventions Go to rounds EBP on MH inteventions 3.3.23 PROMOTING HOLISTIC CARE THROUGH OT 9 Implementation - 10 Implementation - 11 Discontinuation - - 12 Discontinuation - 13 Dissemination - 51 At least 1 patient to fill out questionnaire Weekly check ins with patients Begin case study draft for carpal tunnel patient Add 2 resources to intervention binder At least 1 patient to fill out questionnaire Weekly check ins with patients Complete case study draft for carpal tunnel patient Begin putting all interventions into binder Review edits recommended by CI for carpal tunnel handout draft Clinical experience with ante and postpartum patients Editing case study draft Discuss pts progress with CI, RN, resident Final edits to carpal tunnel handout Final edits to case study Final edits to intervention binder Send to peers for peer review Gather pt history, treatment Discuss pts progress with CI, RN, resident Go to rounds 3.10.23 EBP on MH inteventions Go to rounds 3.18.23 Review references Take pictures for handout Get baby and bottle for pictures 3.24.23 Create treatment plans Put everything together (pictures, research) Create treatment plans 3.31.23 4.7.23 PROMOTING HOLISTIC CARE THROUGH OT 14 Dissemination - Complete PowerPoint presentation Tie up loose ends at site 52 4.14.23  ...

... Implementation of a Transfer Training Program for Non-licensed Patient Care Assistants Zoelaine Taylor Viewegh May 1, 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Dr. Lori Breeden, EdD, OTR Abstract A five-week transfer training program for the certified nursing assistants, personal service aids, home service aids, and student certified nursing assistants was implemented at Bell Trace, an independent and assisted living, short-term rehabilitation, and long-term care facility in Bloomington, Indiana. Using the Person-Environment-Occupation-Performance model (Baum, Christiansen, & Bass, 2015) and Biomechanical frame of reference (Cole and Tufano, 2020) as overarching guidelines, this program was designed around concepts from the coaching training (Jordan et al., 2018) and the microlearning model (Mak et al., 2021). A pre-post test was conducted to determine the effectiveness of the program. Results from a t-test, found a significant improvement in the attitude and knowledge scores of the program participants. A survey modified from Bai, et al, 2018 further explored the effectiveness of the training program. Program participants reported the training was effective and predicted it would be useful to prevent staff injuries and improve patient care. Introduction Bell Trace is a fifteen-acre complex in Bloomington, Indiana owned by CarDon, a family-owned company founded in Greenwood, IN in 1977. Bell Trace offers independent living, assisted living, short-term rehabilitation, and long-term care. The facility also offers outpatient therapy services and home health to assisted and independent living residents. Due to the variety of services, the residents demographics can vary. The long-term care facility houses a 40-45 bed long-term care unit and a 40-45 bed rehabilitation unit. Across the entire facility, most of the residents are 65 and older with a few exceptions for early-onset diseases. After a detailed assessment of the facility, the need for continued staff education on transfers emerged as a consistent topic. Numerous nursing, therapy, and facility managers believe a transfer training program rooted in proper biomechanics would reduce employee injury and improve patient care. High-quality patient care is one of the top priorities at Bell Trace and the facility consistently looks for new ways to increase the safety of its patients and staff. Staff members will complete a five-week training program designed around concepts from the coaching training model (Jordan et al., 2018) and the microlearning model (Mak et al., 2021). With the night-time staff completing a condensed version of the training. The interactive lecture followed by additional opportunities for interactive practice provides the program participants with the best learning environment. Two theories will guide the development of the transfer training project: Person-Environment-Occupation-Performance model (Baum, Christiansen, & Bass, 2015) and the biomechanical frame of reference (Cole and Tufano, 2020). The programs effectiveness will be determined by the results of a pre-test and post-test modified from the Factors Influencing Training Transfers Questionnaire (Bai, et al, 2018) and the Center for Disease Control and Prevention (2022) with construct validity from expert review. Bell Trace will monitor the longterm impact of the transfer training program through their workplace injury reporting. Background Bell Trace is a continuum of care facility with two buildings that house several types of patients. Little Bell is a rehab-to-home and long-term care facility that provides care for patients who are fully dependent to transfer and patients that are able to transfer with little to no assistance. Big Bell is an independent and assisted living facility that requires its residents to be able to transfer with no more than moderate assistance provided by one of the staff members. With the continuum of care, patients from Big Bell are able to transfer to Little Bell once they require more assistance than Big Bell can provide and vice versa. At times, this flow of patients between buildings is a source of contention. The certified nursing assistants (CNAs) transfer patients at Little Bell with different techniques and cues than the personal and home service assistants (PSAs/ HSAs) at Big Bell. The CNAs at Little Bell work closer with the therapy staff and have more opportunities for staff education than the PSAs and HSAs. When patients return to Big Bell, the patients are unfamiliar with the transfer techniques of the Big Bell staff, making consistent patient care difficult to achieve. One of the challenges regarding patient care at Bell Trace is the difference in staff qualifications between buildings. Little Bell employs CNAs whereas Big Bell hires individuals to be PSAs and HSAs. CNAs are required to complete at least 75 initial training hours with a minimum of 16 clinical hours and 12 annual in-service training hours (Trinoff, 2016, p. 501). Whereas, PSAs and HSAs do not have standardized training or education requirements. However, both groups perform the same tasks such as providing showers and assistance for various activities of daily living. Staff at both facilities have physically demanding jobs and are at higher risk for workplace injuries due to the physical nature of the job, the demands of long working hours, and the extreme strain or force applied to the shoulder or back (Van Wyk, 2009). Although there have not been a large number of recorded worker injuries at Bell Trace, with the CNAs/ PSAs/ HSAs providing at least 65 percent of the daily care as identified in Trinkoffs (2016) article on resident care, this creates many opportunities for Bell Trace staff to be injured. During the needs evaluation of the site, staff members participating in the study stated there have been incidents of straining their back or having minor injuries attempting to move a patient, but they did not report those minor incidents to management. According to a study by Darcy et al. (2016), a facility where an injury prevention program exists is 39% less likely for a staff member to be injured on the job. A transfer training program will provide staff with the opportunity to bridge the gap between staff transfer techniques in both buildings as well as educate staff members on the proper biomechanics for safe transfers to reduce workplace injury. To address the gaps in transfer techniques, several individuals were involved in the development of the project. One-on-one meetings occurred with the director of nursing, the assistant director of nursing, and the therapy supervisors. The nursing and therapy supervisors were very interested in the project and felt it could improve the well-being and work satisfaction of the staff by reducing the mild strains staff experience on a frequent basis and improving the level of patient care provided by the staff. Explementary work satisfaction and staff well-being in addition to high-quality patient care are what CarDon facilities strive to achieve. Each building had different approaches to ensure staff engaged in the opportunity for continuing education, but each facility was provided a QR code linked to a Google Form to provide suggestions for the training. With the transfer training designed to fit the needs of the staff, the study is more likely to be well received (Hunter et al. 2019). Following staff recruitment, staff members in both buildings were willing to sign up for the study due to the incentives and personal stake in the continuing education plan. Feedback provided by staff members and supervisors, in addition to an examination of the continuing education literature, was compiled to design a five-week training program for day staff and a condensed training program for night staff. Keeping with CarDons mission for community engagement and community partnership, a two-week training program was offered to the Morgan County Community College (MCCC) certified nursing assistant students. The program was designed from a coaching training intervention model (Jordan et al., 2018) and microlearning (Mak et al., 2021). By using a coaching training model instead of the standard lecture-based learning method, the staff members are provided with an opportunity to engage with the material in real-world simulated lessons but still receive handouts and informational videos to continue their learning (Noetel, et al, 2021). Following each training session with opportunities for at least one microlearning follow-up per session provides the program participants the flexibility to learn the skills taught in training but reduces the time spent in a classroom setting. Additionally, microlearning opportunities while performing hands-on patient care allow for the development of more personalized patient care (Varadhan, 2021). The study design addresses limitations from prior studies. To address the limitation of lack of staff participation as noted by Gray et al. (2016) in prior studies, staff were provided with multiple opportunities to be involved in the design of the program. Yeatts 2010 found a training program designed with feedback from those participating in the study had a very positive impact on the CNAs attitude toward their job which may increase each participants likelihood to continue using the correct transfer form following the training program. Two additional adjustments were made to correct limitations from other studies such as lack of time and small sample sizes. The transfer training program was designed to have very short sessions to reduce the amount of time the CNAs are not able to assist patients. Another issue noted by Van Wyk et al. (2009) was the small number of program participants who came from the same background. The transfer training program will examine the increase in knowledge and improved attitude toward the study from three participant pools. Furthermore, this study explores transfer techniques with two different buildings of patients, providing more than one clinical site in this study as compared to Van Wyks study (2009). Guiding Theory The Person-Environment-Occupation-Performance model provides the necessary guidelines to create a training program for CNAs working in a long-term care facility and PSAs/ HSAs in assisted living and independent living. The doctoral capstone will explore ways staff at Bell Trace can increase their knowledge in transfer techniques, body positioning, and correctly moving the patient. The PEOP model offers an analysis of the entire organization which would allow systematic changes (Baum, Christiansen, & Bass, 2015). By changing the approach at the organizational level, training will be offered to current staff as well as new hires. The model will guide the collection of data through assessments that evaluate the person, environment, occupation, and performance on an organizational level. The site does not offer transfer training, but a need is present for staff members to have opportunities for additional training. The occupational therapists at the facility have noticed a lack of biomechanical knowledge in the way the staff manages their patients. Deformities lead to a lack of function and revert the progress made in both occupational and physical therapy. Placing patients in incorrect positions within a sedentary position could cause great harm to the patient. A training program with an organizational view (PEOP) will guide the staff in the correct body positioning within wheelchairs and the proper biomechanical form to perform each transfer technique. The training program will be created through the Biomechanical frame of reference and its principles of the base of support and center of gravity (Cole and Tufano, 2020). By having a sound understanding of anatomical principles, the staff will be able to provide a higher level of care to their patients. The facility, Bell Trace, will benefit from better-trained employees by seeing an increase in staff compliance and a decrease in patient and staff injury. Project Design The project was designed to improve consistency in patient care and prevent workplace injuries and create a program that could be implemented at both Bell Trace buildings. This program will create a standardized approach to patient transfers that will be used across buildings. The pilot study will determine what changes may need to be made to the training material to create effective transfer training for new staff members hired at Little Bell and Big Bell. A pre-training and post-training survey was created to evaluate the program participants change in attitudes as well as knowledge based on the study objectives. A delayed post-training survey assesses the programs overall effectiveness in addition to the pre-training and posttraining surveys. The attitudes portion of the pre-training & post-training survey and the overall training program effectiveness were modified from the Factors Influencing Training Transfer (FITT) with the authors permission (Bai, et al, 2018) (Appendix A). This assessment tool was developed for nurses to determine the retention of information following training. The validity and reliability of the FITT tool were studied extensively and construct validity & internal consistency were established. To maintain the validity and reliability of the tool, two subsections: factors three and five which were overall training effectiveness and attitudes respectively, were used in its entirety. However, the knowledge portion of the pre-survey and post-survey was not tested by a large study. The knowledge portion of the pre-training and the post-training survey was created to mirror the learning objectives for the transfer training using the Recommended Training Effectiveness Questions for Postcourse Evaluations. This user guide was developed by the Centers for Disease Control and Prevention to create an evaluation that can give better predictions about learning outcomes (CDC, 2019, p. 4). Additionally, the knowledge questions were evaluated by an expert in the field to establish construct validity. Within each learning module, competency forms were modified from the Washington State Department of Health National Nurse Aide Assessment Program (NNAAP) (2019). Each transfer competency form will be completed during the one-on-one microlearning sessions following the discussion-based lecture session. The program will occur over the course of five weeks, but the number of sessions per group varies. Appendix B displays the number of sessions each group completed as well as the material covered in each session. The following observation days provide different options for follow-up based on the program participants work schedule. Due to an inconsistent work schedule, training sessions may have to be completed individually, limiting the discussion during the initial training module; however, the microlearning sessions provide opportunities to discuss transfers if a patient requires more than one aid to move. The biggest challenge to implementing this project was working around different schedules and the incredibly busy workday for the program participants. Furthermore, identifying appropriate times to watch the program participants transfer patients for the microlearning proved to be difficult. This was partially due to resistance from the aides being watched as they provide patient care. Even with the challenges facing the project, the supervisors and program participants, particularly the participants at Big Bell and the student nurses, were excited to complete the study and looking forward to the learning outcomes. Project Outcomes Survey data was imported into IBM SPSS Statistics (Version 29) for data analysis and set the alpha level of statistical significance at less than or equal to 0.05. Program participants completed a pre-test and post-test survey to determine if there was a difference in attitudes and knowledge due to the implementation of the transfer training program (Appendix C). The Likert items from the attitude section of the survey were modified from the Factors Influencing Training Transfers Questionnaire (FITT) (Bai, et al, 2018) with the authors written permission. The Likert scale was scored from one as strongly agree and five as strongly disagree. The knowledge portion of the survey was created using the guidelines from the Center for Disease Control and Prevention: Recommended Training Effectiveness Questions for Postcourse Evaluations User Guide (2022) with construct validity from an expert reviewing each Likert question, scored one as not knowledgeable at all to five as extremely knowledgeable (Appendix C). Each Likert item was explored through a calculation of the mean, standard deviations, and confidence intervals for all participants as listed in Table 1. The mean for each attitude and knowledge question was used to run a paired t-test to determine the difference in pre-test and post-test responses. An additional section, the overall training effectiveness, from the FITT questionnaire, was included in the post-test survey along with the attitudes and knowledge questions to gauge the program participants perceptions of the effectiveness of the training program through frequencies (Table 2). There was a significant difference in attitudes regarding the transfer training program between the pre-test and the post-test paired t-test, t (3.80) = 5, p = .013. Program participants had extremely positive attitudes regarding the transfer training with the responses strongly agree and agree being the most frequently selected options on the Likert scale. There was a significant difference between the pre-test and post-test knowledge paired t-test, t (11.05) = 5, p = .0000024 for the group. The student CNAs and staff from Big Bell demonstrated the most improved knowledge scores, particularly with the question Rate your knowledge on each of the specific steps for the following transfers: sit-stand, squat pivot, stand pivot, sliding board, and dependent transfers with a mean difference of m = 1.25 compared to m = .83 (Table 3). The difference in knowledge acquired from the training program could be attributed to the level of education required prior to the transfer training. Staff members at Big Bell do not have any training requirements that must be met before working with the patient. Additionally, the student CNAs were only part of the way through their program, and they had little to no experience transferring patients. The CNAs at Little Bell had more transfer experience as well as more education than the other program participants. To determine how effective each program participant believed the training program was, an overall effectiveness true and false category was added to the post-test. This section was modified from the Factors Influencing Training Transfers Questionnaire (FITT) (Bai, et al, 2018) (Appendix C). The frequencies for each question, as seen in table two, display a unanimous agreement that the training program was effective. Summary Bell Traces aim is to improve the continuity of care between the independent, assisted living, long-term care, and rehabilitation divisions to ensure high-quality patient care and staff satisfaction. This objective was achieved by developing a transfer training program designed to improve clinical continuity across levels of care with a long-term goal of reducing the number of injuries for CNAs and PSAs/ HSAs. Bell Trace supervisors will continue to monitor the impact of the transfer training program to determine if there was a reduction in the number of injuries for the CNAs and PSAs/ HSAs. Therapy and nursing supervisors at the independent and assisted living facility were interested in the injury reduction aspect of the program as well as using the program as a template for future facility-mandated competencies for patient care providers. Using the PEOP and biomechanical theories to guide the development of the training material content, program participants underwent a five-week program training program designed around concepts from the coaching training model (Jordan et al., 2018) and the microlearning model (Mak et al., 2021). Each week focused on a different topic from biomechanical principles, seven transfer techniques, fall recovery strategies, to wheelchair positioning. Program participants completed a pre-test and post-test survey to determine the effectiveness of the program. A significant improvement in attitudes, t (3.80) = 5, p = .013, and knowledge scores, t (11.05) = 5, p = .0000024, was identified with a t-test, indicating a positive outcome of the training program. Furthermore, an overwhelming majority of the program participants, as noted in table two, agreed that the transfer training program was effective and useful for the improvement of everyday transfers. Several staff members stated their confidence in their ability to transfer patients has greatly increased following the training. Thus improving the staffs ability to provide high-quality patient care across the continuum of care at Bell Trace. Conclusion Designing a transfer training program for an entire campus was a complicated process due to the irregular schedules of staff in either building and the diverse patient population. However, the results far outweigh the difficult planning process and implementation. Staff members demonstrated improved knowledge of transfer techniques and an enhanced understanding of biomechanical principles will reinforce proper transfer techniques to attempt to reduce the prevalence of staff injury. Multiple program participants stated they felt much more confident in their ability to transfer patients and provide high-quality patient care to patients that are more difficult to transfer. The therapy supervisor will provide this transfer training to newly hired CNA and PSA/HSA staff during staff orientation. The training for new staff will utilize the handouts, videos, and a presentation designed specifically for new hires to ensure a successful transfer of learning from the training session to patient care. The transfer training program was designed through the unique lens of occupational therapy and was created to recognize all aspects of occupational performance, not just the technical aspect of how to perform a transfer. Program participants learned how to communicate with the patients, how to adjust cueing styles based on the patient and their diagnosis, and how to prepare the environment to optimize safety. It would be beneficial for future occupational therapy studies to explore the long-term effects of a transfer training program to determine how well the training program reduces injuries and improves patient care. References Bai, et al. (2018). BMC Health Services Research, 18(107). https://doi.org/10.1186/s12913-0182910-7. Baum, C., Christiansen, C., & Bass, J. (2015). Person-Environment-Occupational Performance (PEOP) Model. In C. Christiansen, C. Baum, J. Bass, Occupational Therapy: Performance, Participation, Well-being. (4th ed.). Thorofare, NJ: Slack. Centers for Disease Control and Prevention. Recommended Training Effectiveness Questions For Postcourse Evaluations User Guide Atlanta, GA: CDC, 2019. Cole, M. & Tufano, R. (2020). Applied theories in occupational therapy: A practical approach. (2nd Ed.). Thorofare, N.J.: SLACK Inc. Darcy, L., Sasai, Y., & Sterns, S. (2016). Do assistive devices, training, and workload affect injury injury incidence? Prevention efforts by nursing homes and bac injuries among nursing assistants. Journal of Advanced Nursing 68(4), 836-845. https://doi: 10.1111/j.1365-2648.2011.05785.x Gray, M. et al. (2016). Meaning making in long-term care: What do certified nursing assistants think? Nursing Inquiry, 23(3), 244-252. https://DOI: 10.1111/nin.12137 Hunter et al. (2019). The feasibility of implementing education on older person care to practice on medical units: Nurses perceptions and the influence of practice context. International Journal of Older People Nursing, 14(e12265). Https://doi.org/10.1111/opn.12265. Jordan, J., et al. (2018). Feasibility of testing a coaching training intervention for CNAs in nursing homes. Geriatric Nursing, 39(6), 702708. https://doi.org/10.1016/j.gerinurse.2018.05.009 Mak, W., et al. (2021). Research needed on microlearning as a training strategy for CNAs in skilled nursing facilities. Journal of the American Medical Directors Association, 22(12), 26102611. https://doi.org/10.1016/j.jamda.2021.07.025 Noetel, M., Griffith, S., Delaney, O., Sanders, T., Parker, P., del Pozo Cruz, B., & Lonsdale, C. (2021). Video Improves Learning in Higher Education: A Systematic Review. Review of Educational Research, 91(2), 204236. https://doi.org/10.3102/0034654321990713 Trinkoff, M., et al. (2016). CNA training requirements and resident care outcomes in nursing homes. The Gerontologist, gnw049. https://doi.org/10.1093/geront/gnw049 Yeatts, D. E., et al. (2010). The Perception of Training Availability among certified nurse aides: Relationship to CNA performance, turnover, attitudes, burnout, and empowerment. Gerontology & Geriatrics Education, 31(2), 115132. https://doi.org/10.1080/02701961003795722 Van Wyk, P., Andrews, D., & Weir, P. (2009). Nurse perceptions of manual patient transfer training: Implications for injury. IOS Press, Work 37, 361-373. https://DOI 10.3233/WOR-2010-1090 Varadhan, R. (2021). Research needed on microlearning as a training strategy for CNAs in skilled nursing facilities. Letters to the Editor- Journal of the American Medical Directors Association, 22, 2609-2611. Washington State Department of Health National Nurse Aide Assessment Program (NNAAP). (2018). Washington State Department of Health. Table 1 Descriptive Statistics for Pre-training and Post-training Survey Section Question Attitudes 1 2 3 4 5 6 1.14 1.64 1.32 1.27 1.23 1.27 1.09 1.18 1.05 1.05 1.09 1.05 .351 .581 .477 .456 .429 .456 .294 .501 .213 .213 .294 .213 .98-1.29 1.38-1.89 1.11-1.53 1.07-1.47 1.04-1.42 1.07-1.47 .96-1.05 .96-1.4 .95-1.14 .95-1.14 .96-1.22 .95-1.14 1 2.42 4.17 1.08 .835 1.73-3.11 3.64-4.70 2 3 4 3.25 3.92 4 4.67 4.83 4.83 1.14 1.08 1.13 .651 .389 .389 2.53-3.97 3.23-4.61 3.28-4.72 4.25-5.08 4.59-5.08 4.59-5.08 5 6 2.92 3.92 4.83 4.83 2.5 .793 .577 .389 1.37-4.46 3.41-4.42 4.47-5.2 4.59-5.08 Knowledge Mean Pre-test Post-test Standard Deviation Pre-test Post-test Confidence Interval Pre-test Post-test Table 2 Frequency of the Overall Effectiveness for the Transfer Training Frequency Question True False 1 22 0 2 22 0 3 22 0 4 22 0 5 22 0 6 22 0 7 21 1 8 22 0 9 22 0 Table 3 T-test for Rate your knowledge on each specific step of the transfer Group Big Bell Little Bell Student CNAs Note- P < .05* Mean Difference T-value Degrees of Freedom P-value 1.25 .83 1.25 3.191 2.71 5.00 11 5 3 .009* .042 .015* Appendix B Figure 1 Schedule for Transfer Training Program Master Schedule for Little Bell and Big Bell Training Program Week/ Session Number: Monday Tuesday Wednesday Thursday Friday Jan. 30 10:00 AMTraining Option 1 at LB Day 2:30 PMTraining Option 2 at LB Day Jan. 31 10:00 AMTraining Option 3 at LB Day 2:30 PMTraining Option 4 at LB Day Feb. 1 Feb. 2 Feb. 3 LB Night Training6:30 and 7:30 Feb. 6 Week 5Session 1 Observation Observation Observation at LB at LB at LB Ses. 1: biomechanical, gait belt, sitstand Observation Observation Observation at LB at LB at LB 10:00 AMTraining Option 1 at BB Day 2:30 PMTraining Option 2 at BB Day Week 4Session 1: 5:00 PMTraining at BB Night Training Handouts 10:00 AMTraining Option 3 at BB Day 2:30 PMTraining Option 4 at BB Day Observation at BB Ses. 1: biomechanical, gait belt, sitstand Observation at BB Ses. 1: biomechanical, gait belt, sitObservation Observation Observation Observation stand/ bed mobility and verbal cues/ squat pivot Feb. 7 Feb. 8 Feb. 9 Feb. 10 Ses. 1: biomechanical, gait belt, sitstand/ bed mobility and Observation Observation Observation Observation verbal cues/ squat pivot/ stand pivot/ slide board/ positioning 10:00 AMTraining Option 1 at LB Day 2:30 PMTraining Option 2 at LB Day Week 5Session 2 Observation Observation at BB at BB Observation Observation at BB at BB Feb. 13 Week 6Session 2 Week 6Session 3 10:00 AMTraining Option 3 at LB Day 2:30 PMTraining Option 4 at LB Day LB Night Training6:30 and 7:30 10:00 AMTraining Option 1 at LB Day 2:30 PMTraining Option 2 at LB Day Observation Observation Observation at LB at LB at LB Observation Observation Observation at LB at LB at LB 10:00 AMTraining Option 1 at BB Day 2:30 PMTraining Option 2 at BB Day 10:00 AMTraining Option 3 at BB Day 2:30 PMTraining Option 4 at BB Day Observation at BB Observation at BB Ses. 2: bed mobility, verbal cues, squat pivot, and stand pivot Ses. 2: bed mobility, wheelchair positioning, and verbal cues Ses. 1: biomechanical, 7:15 AM gait belt, sitNS stand/ bed Observation Training mobility and Session verbal cues, squat pivot/ stand pivot Feb. 14 Feb. 15 Feb. 16 Feb. 17 Ses. 2: stand pivot/ slide Observation Observation Observation Observation board/ dependent and positioning 10:00 AMTraining Option 3 at LB Day 2:30 PMTraining Option 4 at LB Day Observation Observation at BB at BB Observation Observation at BB at BB Observation Observation Observation at LB at LB at LB Observation Observation Observation at LB at LB at LB 10:00 AMTraining Option 1 at BB Day 2:30 PMTraining Option 2 at BB Day 10:00 AMTraining Option 3 at BB Day 2:30 PMTraining Option 4 at BB Day Observation at BB Observation at BB Ses. 3: Slide board Ses. 3: squat pivot/ stand pivot Week 7Session 4 Feb. 20 10:00 AMTraining Option 1 at LB Day 2:30 PMTraining Option 2 at LB Day Feb. 21 10:00 AMTraining Option 3 at LB Day 2:30 PMTraining Option 4 at LB Day Observation Observation at BB at BB Observation Observation at BB at BB Week 8Session 5 Feb. 22 7:15 AM NS Training Session Feb. 23 Observation Feb. 24 Observation Observation Observation at LB at LB at LB Observation Observation Observation at LB at LB at LB 10:00 AMTraining Option 1 at BB Day 2:30 PMTraining Option 2 at BB Day Mar. 1 10:00 AMTraining Option 3 at BB Day 2:30 PMTraining Option 4 at BB Day Mar. 2 Observation at BB Observation at BB Feb. 27 Feb. 28 Mar. 3 10:00 AM- 10:00 AMTraining Training Observation Observation Observation Option 1 at Option 3 at at LB at LB at LB LB Day LB Day 2:30 PM2:30 PMTraining Training Observation Observation Observation Option 2 at Option 4 at at LB at LB at LB LB Day LB Day Observation Observation at BB at BB Observation Observation at BB at BB Ses. 2: slide board and dependent transfer Ses. 4: Dependent transfer, wheelchair positioning, and Postsurvey Ses. 4: slide board and Post-training survey Ses. 5: Makeup Week Key: Little Bell (LB) Day Staff Big Bell (BB) Day Staff Nursing Students (NS) Little Bell (LB) Night Staff Big Bell (BB) Night Staff Appendix C Figure 1 Pretraining Attitude Survey 1=strongly agree, 2= agree, 3= neutral, 4= disagree, 5=strongly disagree Question: Attitudes I believe the training should be shared and applied in the organization 1 2 3 4 5 4 5 The purpose of my attendance in the training is to resolve the problem in the workplace with the use of my training I have a duty to use the training in the workplace effectively after the training The application of the training is good for my personal development I will learn actively in the training because I treasure this training opportunity Effective use of the training meets the requirement of the development of my organization Note: Modified from the FITT Questionnaire (Factors Influencing Training Transfers) Figure 2 Pretraining Knowledge Survey 1= not at all knowledgeable, 2= slightly knowledgeable, 3= moderately knowledgeable 4=very knowledgeable, 5= extremely knowledgeable Knowledge Question: How much do you know about the concept of biomechanical principles? 1 2 3 How much do you know about the concept of wheelchair positioning? I ensured I created a safe transfer environment with the use of a gait belt and a clear pathway for the transfer. I helped my patient understand all the steps of the transfer. I understand how to correctly size a hoyer lift sling to each patient. Rate your knowledge on each of the specific steps for the following transfers: sit-stand, squat pivot, stand pivot, sliding board, and dependent transfers. Do you feel like you have strained yourself (i.e. back, neck, etc) or injured yourself as you transfer a patient? Does this happen often? Please explain the situation. Figure 3 Porttraining Attitude Survey 1=strongly agree, 2= agree, 3= neutral, 4= disagree, 5=strongly disagree Question: Attitudes I believe the training should be shared and applied in the organization 1 2 3 4 5 The purpose of my attendance in the training is to resolve the problem in the workplace with the use of my training I have a duty to use the training in the workplace effectively after the training The application of the training is good for my personal development I learned actively in the training because I treasured the training opportunity Effective use of the training meets the requirement of the development of my organization Note: Modified from the FITT Questionnaire (Factors Influencing Training Transfer) Figure 4 Posttraining Knowledge Survey 1= not at all knowledgeable, 2= slightly knowledgeable, 3= moderately knowledgeable 4=very knowledgeable, 5= extremely knowledgeable Knowledge Question: How much do you know about the concept of biomechanical principles? How much do you know about the concept of wheelchair positioning? I ensured I created a safe transfer environment with the use of a gait belt and a clear pathway for the transfer. I helped my patient understand all the steps of the transfer. I understand how to correctly size a hoyer lift sling to each patient. Rate your knowledge on each of the specific steps for the following transfers: sitstand, squat pivot, stand pivot, sliding board, and dependent transfers. 1 2 3 4 5 Figure 5 Posttraining Overall Effectiveness Survey Overall Training Effectiveness Question: The interactive atmosphere in the training could help me grasp the training content The training method was versatile and flexible which helped me improve my learning efficiency The training method was practice-oriented which helped me apply my learning on the job easily The training was trainee-centered which facilitated my grasp of the training content The training will help me resolve substantive matters in the workplace The trainer gave me an evaluation and feedback about my learning after the training The training focused on the problems to be resolved in the workplace The training helps me improve my work capability The training matched my work requirements True False Appendix D Table 1 Capstone Project and Experience Goals Week 1 DCE Stage Orientation & Screening/ Evaluation Weekly Goal A- The student will gain administration skills during the capstone project by sitting in on Medicare care plan meetings and learning how to manage rehabilitation staff. Objectives A- The student will attend at least 5 Clinical Meetings throughout the capstone experience. B- After the first three weeks of the capstone experience, all checklists and training materials will be prepared for the CNA training program to increase CNA knowledge in care for rehabilitation care at Bell Trace. 2 Screening/ Evaluation A- The student will gain experience and knowledge in understanding how to treat patients with dementia by working in the clinic for at Tasks Date complete A- I attended several meetings this week, including my first Clinical Meeting where patient concerns were discussed with various partners. I was reoriented to the site and managers/ supervisors at Bell Trace as I attended different meetings. I was at Bell Trace for my first Level II fieldwork rotation. This allowed me an opportunity to discuss the project and receive feedback from stakeholders. Jan. 13th B- I used the information gained during the meetings to guide me as I began working on my training materials. I spent most of my time this week gathering information and new literature to guide my project. A- The student will downgrade and upgrade intervention plans based on the Brief Cognitive Rating Scale. A- I treated several patients this week and determined one of the patients would benefit from a cognitive screening. I administered the Brief Cognitive Rating Scale to adjust my treatment plan and education approach based on the results. Jan. 20th least two weeks. B- The student will gain administration skills during the capstone project by sitting in on Medicare care plan meetings and learning how to manage rehabilitation staff. C- After the first three weeks of the capstone experience, all checklists and training materials will be prepared for the CNA training program to increase CNA knowledge in care for rehabilitation care at Bell Trace. 3 Screening/ Evaluation A- The student will gain experience and knowledge in understanding how to treat patients with dementia by working in the clinic for at least two weeks. B- After the first three weeks of the capstone experience, all checklists and training materials will be prepared for the CNA training program to increase CNA knowledge in care for rehabilitation care at Bell Trace. B- The student will learn how to supervise therapists on the rehabilitation staff by shadowing the lead therapist who manages the unit at least once every other week. C- By the second week, the DCE student will design the pre-training survey. A1- The student will learn basic information about dementia screening and assessment tools. A2- The student will downgrade and upgrade intervention plans based on the Brief Cognitive Rating Scale. B1- By the third week, the training modules will be designed. B2- By the second week, the DCE student will design the B- I attended the monthly Bridge Meeting between Big Bell and Little Bell which provided me the opportunity to discuss my project. I was able to mention how beneficial my project will be to both buildings. C- I located information to create a pretest and posttest for my training, but I am waiting on responses from the authors to modify them. I continued to work on my training handouts and scheduled time during week three to record my training videos. A1- I administered the brief cognitive screen as well Jan. 27th as the MOCA to a patient this week. A2- The outcomes on the assessments will guide my treatment plan and how I upgrade/ downgrade tasks. B1- All of the training handouts were finished this week. I am waiting to gain access to a video editing program to finish editing some of my videos. The competency sheets for each transfer were modified from the Washington State Department of Health National Nurse Aide Assessment Program (NNAAP). pre-training survey (late). B3- A logic model will be used to create a master schedule and four session schedules for the B2- Although one week late, the pre-training and post-training survey was finalized this week. B3- The logic model was modified to create a master schedule for the training modules. Instead of building a graphic to display the schedule, excel program participants to reference as they complete study was used to outline each session which lead to the requirements. end of the program. 4 Implementation A- The student will gain administration skills during the capstone project by sitting in on Clinical Meetings and learning how to manage rehabilitation staff. B- The student will gain experience and knowledge in understanding how to treat patients with dementia by working in the clinic for at least two weeks. C- By the fourth week of the capstone experience, the CNA training modules will begin to be taught to the program participants as well as administration of the preknowledge and technical skills survey. A1- The student will attend at least 5 Clinical Meetings throughout the capstone experience. A1- I went to the Clinical Meeting and several morning meetings at Big Bell this week. I developed my skills as a supervisor by discussing patient progress and concerns about residents. A2- The student will learn how to supervise therapists on the rehabilitation staff by shadowing the lead therapist who manages the unit at least once every other week. A2- During the meetings I attended this week, I talked to my capstone advisor about patients that should be screened for therapy services to see if they would benefit from being on caseload. B1- The student will learn basic information about dementia screening and assessment tools. B2- The student will downgrade and upgrade intervention plans based on the Brief Cognitive Rating Scale. B1- I continued to use the outcome of the Brief Cognitive Screening tool to guide my intervention plans for several of my patients. B2- I reached out to a speech therapist this week to see if he had any ideas for my intervention sessions with a mild cognitively impaired patient. C1- I continued to host training sessions Monday through Thursday at Little Bell and Big Bell. It has been difficult providing the training session to each program participant due to varying schedules, but I Feb. 3rd C1- Over the next five weeks, the training modules will be taught to the CNAs. C2- The DCE student will meet with each CNA at least one time per module to answer questions and observe technical skills. am able to provide the resources and videos to the participants that cannot attend or reschedule them for a different day. I follow up with them during the week for the microlearning sessions. C2- I have been trying to follow up with each CNA at least one time per week. I may not be able to witness the CNA transfer a patient each time, but the CNA has the opportunity to ask any follow-up questions or provide additional commentary. 5 Implementation A- The student will gain administration skills during the capstone project by sitting in on Clinical Meetings and learning how to manage rehabilitation staff. B- The student will gain experience and knowledge in understanding how to treat patients with dementia by working in the clinic for at least two weeks. C- By the fourth week of the capstone experience, the CNA training modules will begin to be taught to the program participants as well A- The student will attend at least 5 Clinical Meetings throughout the capstone experience. A- I attended the Clinical Meeting this week to listen to other staff members discuss patient care. As I learn more about each of the residents, I am able to provide more useful information to the team. B1- The student will learn basic information about dementia screening and assessment tools. B1- I continued to use the data provided from the Brief Cognitive Rating Scale and the MOCA to guide my treatment sessions for my patients with cognitive impairment. B2- The student will downgrade and upgrade intervention plans based on the Brief Cognitive Rating Scale. C1- Over the next five weeks, the training modules will be taught to the CNAs. C2- The DCE student will meet B2- Based on the patients results on the assessment tools, I created an intervention plan for the patients to follow. C1- Training modules are still being implemented with the staff. C2- I have not been able to watch each staff member transfer a patient each week, but I have Feb. 10th 6 Implementation as administration of the preknowledge and technical skills survey. with each CNA at least one time per module to answer questions and observe technical skills. briefly met with them each week to discuss how their progress has been each week. A- The student will gain administration skills during the capstone project by sitting in on Clinical Meetings and learning how to manage rehabilitation staff. A1- The student will attend at least 5 Clinical Meetings throughout the capstone experience. A1- This week at Clinical Meeting, we discussed one patient at length. This patient was becoming more difficult for the staff to manage in an assisted living facility and the managers were trying to determine the best option to care for the patient. It was interesting to watch the managers thought processes and learn about what they considered most important to address. B- The student will gain experience and knowledge in understanding how to treat patients with dementia by working in the clinic for at least two weeks. C- By the fourth week of the capstone experience, the CNA training modules will begin to be taught to the program participants as well as administration of the preknowledge and technical skills survey. A2- The student will learn how to supervise therapists on the rehabilitation staff by shadowing the lead therapist who manages the unit at least once every other week. B1- The student will learn basic information about dementia screening and assessment tools. B2- The student will downgrade and upgrade intervention plans based on the Brief Cognitive Rating Scale. C1- Over the next five weeks, the training modules will be taught to the CNAs. C2- The DCE student will meet with each CNA at least one time per module to answer questions and observe technical skills. A2- My capstone advisor was writing the yearly evaluations for the staff she oversaw. We did not discuss specific individuals performances, but we talked about what are good or poor qualities to have in a staff member. B1- I spent the week becoming more familiar with the components of dementia screening tools and assessments and how each section can lead to intervention development. B2- I used the outcomes of the assessment tools to determine what interventions would be best for my cognitively impaired patients. C1- Training modules are still being implemented with the staff. C2- I was able to watch a few staff members perform transfers this week. For those I was not Feb. 17th able to watch, we touched base to see how they felt about the lesson that week. I worked with the staff one-on-one to transfer several specific patients to ensure proper transfer technique was being used. 7 Implementation A- The student will gain experience and knowledge in understanding how to treat patients with dementia by working in the clinic for at least two weeks. B- By the fourth week of the capstone experience, the CNA training modules will begin to be taught to the program participants as well as administration of the preknowledge and technical skills survey. 8 Implementation A- The student will gain administration skills during the capstone project by sitting in on Clinical Meetings and learning how to manage rehabilitation staff. A- The student will downgrade and upgrade intervention plans based on the Brief Cognitive Rating Scale. B1- Over the next five weeks, the training modules will be taught to the CNAs. B2- The DCE student will meet with each CNA at least one time per module to answer questions and observe technical skills. A1- The student will attend at least 5 Clinical Meetings throughout the capstone experience. A2- The student will learn how to supervise therapists on the A- I have maintained a steady caseload each day to continue developing my skills as a future practitioner. Not all of my patients are cognitively impaired, but I do have several individuals on my schedule that require assistance with compensatory strategies. Feb. 24th B1- Training modules are still being implemented with the staff. B2- There was a COVID-19 outbreak this week which made it difficult to work with all the staff members. Unfortunately, the staff and residents were affected. Therefore, I could not watch the staff transfer patients because many residents tested positive and had to remain in isolation in their rooms. I was able to discuss different patients and related transfer techniques with the staff members. A1- I have been working with a patient that has transitioned between Little Bell and Big Bell several times in both buildings. This has allowed me to provide a very interesting level of care because I know the patients history so well. I have enjoyed the level of care I can provide and the information I can provide to the interprofessional Mar. 3rd B- The student will gain experience and knowledge in understanding how to treat patients with dementia by working in the clinic for at least two weeks. C- By the fourth week of the capstone experience, the CNA training modules will begin to be taught to the program participants as well as administration of the preknowledge and technical skills survey. D- By the eighth week of the capstone experience, the CNA training will be completed and the postknowledge and technical skills survey as well as the therapist satisfaction survey will be given to the program participants at Bell Trace. rehabilitation staff by shadowing the lead therapist who manages the unit at least once every other week. B -The student will learn basic information about dementia screening and assessment tools. C1- Over the next five weeks, the training modules will be taught to the CNAs. C2- The DCE student will meet with each CNA at least one time per module to answer questions and observe technical skills. D1- The student will meet with the assistant nursing director at least once to discuss her recommendations and overall thoughts about the training protocol. D2- The CNAs, therapists, and nursing supervisors will have until the end of the ninth week to complete the post-training and feedback surveys. team as I work within the continuum of care at Bell Trace. A2- My capstone advisor discussed how she handles speaking to staff about constructive feedback and how to address those difficult conversations. B- I feel like I have gained a lot of knowledge and experience administering the MOCA. I used the MOCA to evaluate another patient with cognition concerns. C1- Training modules are still being implemented with the staff. C2- Due to the irregular staff schedules, it was difficult to find time to meet with the staff one-onone. However, I was able to make myself present for the staff to check in with and determine how their transfers have been going. D1- I touched base with the assistant nursing director to discuss the end of the training program and to give her the completed certificates for the staff members that participated in the training. D2- I was able to have all the program participants complete and turn the post-survey in during week eight. 9 Implementation A- The student will gain administration skills during the capstone project by sitting in on Clinical Meetings and learning how to manage rehabilitation staff. B- By the fourth week of the capstone experience, the CNA training modules will begin to be taught to the program participants as well as administration of the preknowledge and technical skills survey. C- By the eighth week of the capstone experience, the CNA training will be completed and the postknowledge and technical skills survey as well as the therapist satisfaction survey will be given to the program participants at Bell Trace. 10 Discontinuation A- The student will gain administration skills during the capstone project by sitting in on Clinical Meetings and learning how to manage rehabilitation staff. A1- The student will attend at least 5 Clinical Meetings throughout the capstone experience. A2- The student will learn how to supervise therapists on the rehabilitation staff by shadowing the lead therapist who manages the unit at least once every other week. B -The DCE student will meet with each CNA at least one time per module to answer questions and observe technical skills C- The student will meet with the assistant nursing director at least once to discuss her recommendations and overall thoughts about the training protocol. A1- The student will attend at least 5 Clinical Meetings throughout the capstone experience. A2- The student will learn how to supervise therapists on the A1- I attended morning meetings this week and discussed patient concerns as well as events occurring on campus. Mar. 10th A2- My capstone advisor finally found the time to review evaluations with the staff. My advisor did not name the employees, but we discussed positive and negative traits to have in employees. B- I set time aside this week to meet with any program participants last minute for any follow-up to the training program. C- I met with the assisted nursing director to discuss project sustainability and the best way to capture newly hired staff in the future. We determined a small presentation during orientation would be best. This will be completed by the therapy supervisor. A1- I attended the Bridge Meeting which is a campus partner meeting that occurs once a month. Individuals from Little Bell and Big Bell attend the meeting to discuss joint community partner events, patients, and facility concerns as a whole. Mar. 17th B- The student will gain experience and knowledge in understanding how to treat patients with dementia by working in the clinic for at least two weeks. C- The student will plan for the dissemination process. 11 Discontinuation A- The student will gain administration skills during the capstone project by sitting in on Clinical Meetings and learning how to manage rehabilitation staff. B- The student will gain experience and knowledge in understanding how to treat patients with dementia by working in the clinic for at least two weeks. C- The student will plan for the dissemination process. rehabilitation staff by shadowing the lead therapist who manages the unit at least once every other week. A2- My capstone advisor was very open about the process for her yearly review. We discussed the review process and what implications there could be following different types of feedback. B- The student will learn basic information about dementia screening and assessment tools. B- I have a patient with Parkinsons Disease whom I have been working with for several weeks. I am beginning to address cognitive decline due to Parkinsons which is very interesting to experience. C- The student will plan for the dissemination process. A- The student will attend at least 5 Clinical Meetings throughout the capstone experience. B- The student will learn basic information about dementia screening and assessment tools. C- The student will create a presentation to disseminate the project to the site. C- I have had several discussions with my capstone advisor and other supervisors to determine the best way to create a sustainable project. A- I attended morning meetings throughout the Mar. week as well as the Clinical Meeting for the week to 24th discuss patient needs and concerns. B- I continued to work with individuals struggling with cognitive decline. I have been working closely with one patient and her family in particular. I have spent a lot of time on caregiver/ family education to ensure the family understands how they can support the patient through the strategies learned in her sessions. C- I reached out to the administrators in Little Bell and Big Bell to identify a time to disseminate my project. I was able to get this meeting scheduled with both buildings. 12 Discontinuation A- The student will gain administration skills during the capstone project by sitting in on Clinical Meetings and learning how to manage rehabilitation staff. B- The student will gain experience and knowledge in understanding how to treat patients with dementia by working in the clinic for at least two weeks. C- The student will plan for the dissemination process. A1- The student will attend at least 5 Clinical Meetings throughout the capstone experience. A2- The student will learn how to supervise therapists on the rehabilitation staff by shadowing the lead therapist who manages the unit at least once every other week. B- The student will downgrade and upgrade intervention plans based on the Brief Cognitive Rating Scale. C- The student will create a presentation to disseminate the project to the site. 13 Dissemination A- The student will gain administration skills during the capstone project by sitting in on Clinical Meetings and learning how to manage rehabilitation staff. B- The student will gain experience and knowledge in A- The student will attend at least 5 Clinical Meetings throughout the capstone experience. B- The student will downgrade and upgrade intervention plans based on the Brief Cognitive Rating Scale. A1- I did not attend Clinical Meeting this week due to treating a patient at that time; however, I did go to a few morning meetings this week. I was able to remind individuals my dissemination presentations will occur in week thirteen. Mar. 31st A2- I recorded an About Me video for the marketing department to discuss what occupational therapy is and how my project will benefit the site. This was a great advocacy opportunity and I was able to put the leadership skills I had gained from the capstone experience so far to use. B- After attempting to use various compensatory strategies with one of my patients, I determined I needed to adjust my approach to best serve my patient. I used the BCRS to modify my approach. C- I created a 20-25 minute presentation to correlate with my training handouts for the therapy supervisor to use for new staff hires orientation to continue using the transfer training program information to educate future staff. A- Clinical Meeting was cancelled, but I attended morning meeting to discuss patient concerns and how those concerns should be addressed. B- My Parkinsons patient has declined due to other health concerns and I have had to use several different cognitive strategies to make adjustments to increase the patients safety awareness and sequencing skills. Apr. 7th understanding how to treat patients with dementia by working in the clinic for at least two weeks. C- The student will present the project outcomes to the site. C- I disseminate the project outcomes to both sites this week. The administrators from both buildings were very happy with the outcomes of the program and are interested in continuing the program following the completion of my capstone project. A- The student will attend at least 5 Clinical Meetings throughout the capstone experience. A- I attended my last Clinical Meeting this week. I was able to share a few notes about patients on the outpatient schedule. I attended morning meeting several times this week and worked on addressing patient care. C- The student will disseminate to the site. 14 Dissemination A- The student will gain administration skills during the capstone project by sitting in on Clinical Meetings and learning how to manage rehabilitation staff. B- The student will finish the last steps to fully transition the project to the site. B- The student will complete any last-minute steps to terminate the project. B- I finished several important components of my capstone project and informed each of my patients that I will no longer be treating them. I compiled home exercise programs and other information for each patient and gave it to my capstone advisor to ensure a smooth transition of care. Apr. 14th  ...

... 1 Designing and Implementing Employee Education Resources for a Residential School Serving Children with Disabilities Hannah Tyger, OTD Student May, 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Dr. Laura Aust, OTD, MS, OTR 2 Abstract This project was developed for the recreation department at Damar Services, a residential school facility for children with developmental and behavioral challenges. The project was designed to provide employee education regarding best practices for working with students with disabilities, how to identify sensory challenges and implement sensory regulation techniques, and how to plan for and engage students with disabilities into meaningful play and leisure occupations. The information in the employee education materials was modeled by the student, and education modules were compiled to be used as training materials for future employees of the recreation department. The results of the project revealed that the occupational concepts applied during the recreation classes increased student engagement and participation in physical activities. The education materials created will be implemented into future Damar recreation employee orientation in order to promote staff engagement and knowledge regarding meaningfully engaging students during recreation classes. 3 Designing and Implementing Employee Education Resources for a Residential School Serving Children with Disabilities This project was completed at Damar Services in Indianapolis, Indiana. Damar Services provides many disability support and education services to children and adults throughout the Indianapolis area. This project was designed for the staff of the recreation department at Damars main campus, which is a residential facility where nearly 180 students live, and have the opportunity to attend either the private on-campus school known as Freeway, or the Damar Charter Academy (DCA), which also serves children with disabilities who live in the community. The recreation department is responsible for providing physical education classes throughout the week for all of the classes at Freeway and DCA, as well as after school, weekend, and summer recreational programming. Based on the findings of a needs assessment and several weeks of observation during the school day recreation classes held at Damar Services, it was determined that the staff of the recreation department had limited training on best practices for working with and engaging students with developmental disabilities and behavioral challenges, as well as limited education on how to design activities to promote the students meaningful engagement in physical activity and play. The purpose of this project was initially to provide employee education regarding best practices for working with students with disabilities, how to identify sensory challenges and implement sensory regulation techniques, and how to plan for and engage students with disabilities into meaningful play and leisure occupations. Due to site staffing changes during the course of the capstone, the doctoral student implemented the occupational principles to the recreation classes directly, and created the employee education resources to be incorporated into future employee training. This report will discuss the relevant literature supporting the project, as well as the project design, implementation, and outcomes. 4 Background Necessity for Residential Support Services Residential schools and programs can serve as a vital resource for both children and the families of children with developmental disabilities. These services may become the only available option for students with disabilities that can provide the support and care needed that may not be available to them in traditional school settings or within the care of their families (Gutman et al., 2018). King et al. (2021) found that residential life skills programs can increase student awareness of their own capabilities, as well as providing foundational skills that can be built upon in the future. Another study by this group of researchers discovered the importance of staff engagement and communication skills with the students, especially in providing encouragement and direction (King et al., 2019). This study shows how important the role of staff and caregivers are to the success of the services provided by residential organizations. The current literature surrounding residential organizations for children with developmental disabilities supports their necessity in providing services for an often underserved population. Furthermore, evidence indicates that the staff of these organizations serve in a pivotal role that directly influences the success of these services. Staff Education about Children with Disabilities Employees of residential services for students with disabilities need to be educated on the techniques and intervention strategies that can best support the population served. The primary population that Damar serves is students diagnosed with Autism Spectrum Disorder (ASD). One primary challenge of students with ASD is difficulty participating in and understanding social interactions, and implementation of maladaptive behaviors (Ghanouni et al., 2019). This article further details the frustration that both students and caregivers feel when there is difficulty with 5 communication, and how this can perpetuate a maladaptive cycle. This evidence demonstrates the necessity for staff education about facilitating social and communication skills among the ASD student populations. A review by Arbour-Nicitopoulos et al. (2018) indicates that instructors of physical education classes play an important part in supporting positive social interactions during recreational activities. Further evidence suggests that increased communication leads to better understanding of preferred activities, which is a vital component in promoting participation in physical activity (Stanish et al., 2017). Another study demonstrated that teachers could be educated in sensory interventions to help students with ASD or emotional regulation issues regulate themselves, and after providing education all teachers involved in the study implemented several strategies within the classroom and noted positive results from students (Kaiser, 2020). This provides further evidence to show that education on intervention methods to support students with ASD and other developmental abilities can be effective and provide increased positive outcomes and participation in recreational occupations for the students. Furthermore, it is important to understand specific techniques and recommendations to maximize facilitation of student skill-building and participation in recreational activities. Research indicates that incorporating various types of cueing, such as physical, verbal, and visual, are vital to student learning (Bremer & Lloyd, 2021). Importantly, research suggests that students with disabilities such as ASD participate more in physical activities when they have a higher level of competence and consistency, which indicates that with the correct facilitation techniques, students at Damar can gain confidence, skills, and increase participation in recreational activities (Arnell et al., 2018). 6 Best Practice for Education Implementation Additionally, it is necessary to understand the best practice for fostering employee engagement and participation within their role as a caregiver for students with disabilities. In a study by Scahill et al., researchers found that providing parent training versus parent education for behavioral interventions can lead to overall increased participation in activities of daily living by children with ASD (2016). The study found that providing caregivers with specific training, home visits, role plays, and personalized behavior management interventions, rather than standardized educational materials, led to better outcomes in the ADL category among the children. This is important evidence to incorporate into this educational process, as it will be more effective if it includes personalized training with site specific and meaningful examples and demonstrations. Finally, it is important to recognize the value of an occupational therapy approach to helping facilitate student development and participation in recreational occupations. A review by Taylor et al. (2018) indicates that physical activity interventions positively correlate to motor skill, social skill, and cognitive development. A review by Castro-Kemp & Samuels (2022) also indicated that collaboration across the fields of education, healthcare, and social care support communication across multiple disciplines to create the most holistic care possible. Holistic care is a vital part of occupational therapy practice, and education materials with an occupational perspective can help provide the most beneficial and holistic care for the children at Damar. Needs Assessment Review The needs assessment conducted prior to beginning capstone and expanded upon during the first several weeks of the doctoral capstone experience on site at Damar Services illuminated the specific site needs to be targeted through this project. Primarily, the largest barrier to 7 successful and meaningful service delivery is the lack of staff education and engagement with the students they serve. This causes secondary challenges, such as inconsistent scheduling and expectations, and difficulty identifying the needs of each child. With these challenges in mind, the purpose of this project will be to implement staff education materials designed to improve staff understanding of working with children with disabilities. Additionally, the education materials will emphasize the importance of building meaningful relationships and routines with the children, and improving overall staff engagement during all of the recreation classes that occur throughout the week. Theoretical Background The Person-Environment-Occupation-Performance (PEOP) model guided this DCE project. The PEOP model provides a theoretical basis for considering the intrinsic factors of the person, the extrinsic factors in the environment, and the necessary occupations, while focusing on the success of the performance, which is considered occupational competence (Baum & Bass, 2011). The staff training and education materials designed for Damar Services were created to target current problematic areas related to staffing to educate the staff in the basics of working with students with developmental disabilities, and help to engage the staff into the importance of facilitating participation alongside the students to improve their outcomes. The frame of reference used to guide the project planning was the Cognitive Behavioral Theory. This theory describes the cyclical relationship between thoughts, emotions, and behaviors (Cole & Tufano, 2020). This theory will help me with my program evaluation and employee training design as it will be vital to understand the thoughts and emotions of the employees that are contributing to the current behaviors exhibited that may not be beneficial to the organization, and to help ensure that the training I design will be tailored to address those 8 factors to support the behaviors that will be supportive of the overall goals of the organization. Project Design The project was designed to be a series of education modules specifically for the recreation staff at Damar Services in several areas identified by the needs assessment. The education modules were formatted to begin with an overview of each main topic and emphasize the importance of the material, and included several subsections with specific examples for implementation into existing recreation programming. The topics chosen for the education modules were Increasing Student Engagement, Sensory Processing and Regulation, and Recreation Activity Design. The Increasing Student Engagement module includes a general overview on best practices for working with children with disabilities, as well as more specific information related to some of the more common diagnoses found among students at Damar Services, including Autism Spectrum Disorder, Attention Deficit Hyperactivity Disorder, and Oppositional Defiance Disorder. The Sensory Processing and Regulation module included information regarding how sensory information is processed, how to identify sensory seeking or avoiding behaviors, and how to implement sensory friendly ideas into activities and gym space to help students with sensory regulation. The Recreation Activity Design included general information about how to structure classes to promote engagement, as well as more specific activity ideas tailored to the different types of classes and students that Damar serves. Project Implementation During the course of the DCE, several staffing changes occurred within the recreation department at Damar services. Both of the full-time recreation employees, who were responsible for planning and leading the recreation classes during the week, left their positions in the early weeks of the DCE. As a result, all of the education provided in the education modules was 9 implemented into the recreational classes directly by the capstone student. Each day, classes were provided with an overview of the schedule for the class, as well as a reminder of student expectations. The schedule remained consistent week-to-week, and activities were graded to provide an appropriate level of challenge for each class. Intentional communication and various forms of verbal, physical, and visual cues were incorporated into all activities to maximize student understanding and participation. Additionally, all educational principles were compiled in the modules as originally designed, with the intention that the recreational director could use them to train future employees of the department. The goal for all the education modules and the implementation of occupational principles into the recreational classes was to increase staff knowledge and demonstrate how to help students with disabilities engage in meaningful activities during recreation classes at Damar services. Project Outcomes The education modules developed for the Damar Services recreation department were created in order to help staff improve their engagement with the students, as well as how to design and implement activities to promote participation in physical activity and sensory integration. The education modules were intended to be designed and taught to the existing employees at the site, and project outcomes were designed to be measured based on employee surveys before and after education from the capstone student. However, due to staffing changes during the course of the project, the student implemented the techniques and approaches found in the modules firsthand through leading the recreation classes. Due to the aforementioned changes, the outcomes of the projects were instead assessed via interviews conducted with the recreation director and assistant director to assess their perspectives on the beneficence of the principles implemented by the student during recreation classes, as well as the educational materials 10 created. The interview method was utilized to understand the recreation director and assistant directors' opinions on the programming implemented by the student, especially the participation and engagement of the students and their care staff during the classes taught by the student, specifically in comparison to these aspects prior to the implementation of the capstone project. Additional questions were asked about the education resources created, in order to determine both knowledge and understanding of the topics, as well as the ability to implement the materials into future employee training. The interview conducted with the recreation director indicated several positive outcomes of the project. In regards to the concepts applied during the recreational classes, the director stated I dont remember a time when the students were this involved or excited during class. He also stated This has given us a good basis for what things should look like around here. In regards to the educational materials, he stated that All of this information is easy to understand and reflects all of the work youve [the capstone student] done here with us. This will be the perfect thing to give to whoever we hire in the future. The interview conducted with the assistant director reinforced several of these outcomes. He agreed that the student participation during classes increased throughout the project implementation, and further stated You [the capstone student] have demonstrated how much of an impact being consistent has on the students, and that is definitely what we need to keep up. He also stated that the educational resources gives really good guidance for people joining the department and felt that providing clear steps and expectations will help them be successful. Overall, both the director and assistant director indicated that the occupational principles implemented into the recreational classes improved participation of both students and direct care staff, and that the educational 11 materials accurately reflected the principles implemented. Additionally, they indicated that the educational materials will be incorporated into future staff training. Summary Residential school facilities, like Damar Services, provide important services for students with developmental disabilities and behavioral challenges. These residential facilities are responsible for facilitating student development, skill-building, and occupational engagement. Employees of these organizations play a vital role in this skill-building process, and research shows that employee education can increase ability to communicate effectively with students and improve student engagement and regulatory skills. Therefore, it is important that employees have educational resources to help maximize knowledge and confidence when working with students at residential facilities. This project was designed for employees at the recreation department of Damar Services to create educational materials to improve staff knowledge and confidence in working with students. Due to staffing changes during the course of the doctoral capstone experience, the recommendations for improving staff and student engagement in physical and recreational activities were implemented directly by the capstone student during recreation classes each week. Classes each week were provided a consistent structure, clear directions and expectations, opportunities for sensory breaks, and multiple forms of cueing to help students remain engaged in activities throughout the class period. Additionally, education materials were created to be used by the recreation director to train future staff of the department and help ensure carryover in the future. The results of the study were measured via interviews conducted with the recreation director and assistant director at the site. The interviews revealed that the programming 12 conducted during the DCE increased student engagement and participation in recreational activities. Additionally, the educational materials provided will be used to train future employees to help promote carryover of results in future classes. Conclusion The goal of this project was to provide educational resources to the recreation department at Damar Services. In conjunction with the materials, all of the recommendations provided were implemented during recreation classes. The implementation of this project benefitted Damar Services in many different ways. Firstly, over 200 students each week attend recreation classes, and throughout the implementation of the project the classes all received increased structure and design to make physical activity more appealing, engaging, and adequately tailored to the ability level of the students. Additionally, the staff of the recreation department gained examples and materials to help increase student participation and engagement, as well as to help train future staff members in maintaining these benefits. Overall, while the work completed at this project was designed specifically for the staff at Damar Services, there may also be further implications for the occupational therapy profession. Current research indicates that there are continued barriers to children with disabilities participating in meaningful recreational and physical play occupations (Carbone et al., 2022). This is an occupational injustice that occupational therapy practitioners have the ability to help address. As indicated by the positive results of the project, it is clear that bringing an occupational therapy perspective into the programming of a developmental school can help improve participation in vital occupations for students with disabilities and behavioral challenges, especially play and leisure, as well as supporting health promotion and wellness through increasing engagement in physical fitness. 13 References Arbour-Nicitopoulos, K. P., Grassmann, V., Orr, K., McPherson, A. C., Faulkner, G. E., & Wright, F. V. (2018). A scoping review of inclusive out-of-school time physical activity programs for children and youth with physical disabilities. Adapted Physical Activity Quarterly 35(1). 11138. https://doi.org/10.1123/apaq.2017-0012 Arnell, S., Jerlinder, K., & Lundqvist, L. (2018). Perceptions of physical activity participation among adolescents with Autism Spectrum Disorders: A conceptual model of conditional participation. Journal of Autism and Developmental Disorders 48(5). 17921802. https://doi.org/10.1007/s10803-017-3436-2 Bremer, E., & Lloyd, M. (2021). Baseline behaviour moderates movement skill intervention outcomes among young children with Autism Spectrum Disorder. Autism : The International Journal of Research and Practice 25(7). 202533. https://doi.org/10.1177/13623613211009347 Carbone, P. S., Smith, P. J., Lewis, C., & LeBlanc, C. (2022). Promoting the Participation of Children and Adolescents With Disabilities in Sports, Recreation, and Physical Activity. PEDIATRICS: American Academy of Pediatrics, 148(6). https://doi.org/10.1542/peds.2021-054664 Castro-Kemp, S., & Samuels, A. (2022). Working together: A review of cross-sector collaborative practices in provision for children with special educational needs and disabilities. Research in Developmental Disabilities, 120, 104-127. https://doi.org/10.1016/j.ridd.2021.104127 14 Christiansen, C., Baum, C. & Bass, J. (2011). The Person-Environment-Occupational Performance (PEOP) model. In E. Duncan (Ed.), Foundations for practice in occupational therapy (5th ed.) (pp. 93-104). Edinburgh, Scotland: Churchill Livingstone Elsevier. Cole, M. & Tufano, R. (2020). Applied theories in occupational therapy: A practical approach (2nd Ed.). SLACK Incorporated. Ghanouni, P., Jarus, T., Zwicker, J. G., Lucyshyn, J., Chauhan, S., & Moir, C. (2019). Perceived barriers and existing challenges in participation of children with autism spectrum disorders: He did not understand and no one else seemed to understand him. Journal of Autism & Developmental Disorders, 49(8), 31363145. https://doi.org/10.1007/s10803019-04036-7 Gutman, L. M., Vorhaus, J., Burrows, R., & Onions, C. (2018). A longitudinal study of childrens outcomes in a residential special school. Journal of Social Work Practice, 32(4), 409421. https://doi.org/10.1080/02650533.2018.1503162 Kaiser, L., Potvin, M.-C., & Beach, C. (2020). Sensory-Based Interventions in the School Setting: Perspectives of Paraeducators. Open Journal of Occupational Therapy (OJOT), 8(3), 111. https://doi.org/10.15453/2168-6408.1615 King, G., Kingsnorth, S., Morrison, A., Gorter, J. W., DeFinney, A., & Kehl, B. (2021). Parents perceptions of the foundational and emergent benefits of residential immersive life skills programs for youth with disabilities. Research in Developmental Disabilities, 110. https://doi.org/10.1016/j.ridd.2021.103857 King, G., McPherson, A. C., Kingsnorth, S., Gorter, J. W., & DeFinney, A. (2019). Intervention strategies in residential immersive life skills programs for youth with disabilities: a study 15 of active ingredients and program fidelity. Developmental Neurorehabilitation, 22(5), 303311. https://doi.org/10.1080/17518423.2018.1497722 Scahill, L., Bearss, K., Lecavalier, L., Smith, T., Swiezy, N., Aman, M. G., Sukhodolsky, D. G., McCracken, C., Minshawi, N., Turner, K., Levato, L., Saulnier, C., Dziura, J., & Johnson, C. (2016). Effect of parent training on adaptive behavior in children with Autism Spectrum Disorder and disruptive behavior: Results of a randomized trial. Journal of the American Academy of Child & Adolescent Psychiatry, 55(7), 602609.e3. https://doi.org/10.1016/j.jaac.2016.05.001 Stanish, H. I., Curtin, C., Must, A., Phillips, S., Maslin, M., & Bandini, L. G. Physical activity levels, frequency, and type among adolescents with and without Autism Spectrum Disorder. (2017). Journal of Autism and Developmental Disorders 47(3), 78594. https://doi.org/10.1007/s10803-016-3001-4 Taylor, L. G., Primucci, M., Irwin, J. D., Teachman, G., & Tucker, P. (2023). The uses and effectiveness of occupational therapy physical activity interventions in young children with developmental disabilities: A systematic review. Physical & Occupational Therapy In Pediatrics. https://doi.org/10.1080/01942638.2023.2199836 16 Appendix A Week 1 DCE Stage (orientation, screening/evaluati on, implementation, discontinuation, dissemination) Orientation Weekly Goal Orient to site Objectives - - 2 Screening/Evaluat ion Finalize needs assessment/M OU - 3 Screening/Evaluat ion Begin compiling staff education resources - - Meet employees of rec department Witness rec class time Meet students and direct care staff Continue shadowing rec classes Start learning student names Talk to rec staff about areas of knowledge/gr owth Determine topics for staff education Assist with rec class time Tasks Date complet e -Worked on project timeline -Started introducing self to students -Met with faculty advisor -Updated goals of MOU 1/9 1/13 -Continued meeting students and learning names -Initiated conversations with direct care staff -Initiated conversations with recreation staff -Drafted intro of scholarly report -Learned structure of students day and organization at Damar -Continued learning student names -Helped with setting up rec classes, assisted with leading activities -Drafted Background 1/16 1/20 1/23 1/27 17 4 Screening/Evaluat ion Continue compiling staff education resources - - - 5 Screening/Evaluat ion Continue Compiling staff education resources - - 6 Implementation Implement education resources into structured classes - - Locate research articles for needed topics Format research with site specific information Continue assisting with rec time; apply principles of occupational therapy during interactions with children Continue researching & developing educational materials Continue working with students Develop pretest based on education materials Administer to staff -Decided educational resource concepts should be organized based on staff education & engagement, sensory integration, and activity ideas and structures -Started planning activities for morning classes d/t no staff present in the morning -Started keeping track of preferred activities for students in ASD classes -Write Design and Implementation -Began implementing expectations at start of class -Began implementing visual and verbal cues into classes with projector & speaker -created outline for Sensory integration module 1/30 2/3 -Increased leadership during majority of classes -Continued implementing structure and expectations to classes taught 2/13 2/17 2/6 2/10 18 - Continue working with students Complete midterm eval with site mentor 7 Implementation Continue implementing educational principles into classes led - Implement group activities for different classes based on principles of OT and demonstratin g materials from education resource 8 Implementation Continue implementing educational principles into classes led - Brainstorm activities for rec time based on education provided Implement preferred activities for Autism Service classes - 9 Implementation Continue implementing educational principles into classes led - - Determine how outcome measures will be assessed based on project changes Continue implementing OT principles -Finished sensory integration education materials -Started outline for facilitating participation -Met with site mentor to discuss Midterm Eval -Restructured project implementation d/t staff no longer working for department -Began leading all recreation classes during the week -Continued compiling participation facilitation materials -continued leading all rec classes throughout the week -Finalized facilitating participation handout -Continued compiling activity ideas and interventions materials - - Continue d leading all recreatio n classes Created poster for rec departme nt to set 2/20 2/24 2/27 3/3 3/6 3/10 19 during classes - 10 Implementation Continue implementing educational principles into classes led - - 11 Implementation Continue implementing educational principles into classes led - 12 Discontinuation Present recreation director and assistant director with educational materials & conduct interviews - - Continue implementing OT principles during classes Design interview to be conducted for final outcomes expectati ons for direct care staff during classes Start drafting outcomes Start determini ng dissemin ation plan - Continued leading all recreation classes -Met with advisor regarding outcome measures -Continued drafting outcomes -Designed interview questions for site mentor & assistant director -Completed dissemination plan -Continued Continue implementing leading all recreation classes OT interventions -Finalized all educational with student materials for groups presentation -Met with director Conduct to present interviews with director materials and and assistant conduct interview -Met with director assistant director Continue implementing to present materials and OT interventions conduct interview 3/13 3/17 3/20 3/24 3/27 3/31 20 with student groups 13 Discontinuation Data analysis - Analyze data Write summary and conclusion of project 14 Dissemination Disseminate to site mentor and staff - Disseminate research Wrap-up working with students - -Continued leading rec classes; began preparing students for capstone ending in two weeks -Noted areas in education resources to edit based on initial review -Made final edits to educational resources -Finalized outcomes draft based on interviews -Continued leading all classes; continued to prepare students for capstone ending next week -Drafted abstract, summary, conclusion -Disseminated to director and assistant director -Presented site with physical and digital copies of educational resources -Taught final classes, thanked students and staff for capstone experience Appendix A. Doctoral Capstone Experience and Project Weekly Planning Guide 4/3 4/7 4/10 4/14  ...

... A Group-Based Education Program for Caregivers of Children with Sensory Processing Dysfunction Taryn J. Springgate, OTS April 24, 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Alissia Garabrant, OTD, MS, OTR 1 Abstract A six-week caregiver education group program focused on sensory processing, behaviors, and strategies, as well as caregiver burnout, was targeted toward caregivers of children with sensory processing dysfunction in the North Shore Pediatric Therapy community. The goal of this project was to increase understanding of sensory processing and reduce caregiver strain through education and resource provision. When measured before group participation, low levels of selfefficacy and confidence aligned with past research. Ratings of knowledge and understanding increased from pre- to post-test across topics, indicating increased understanding on average. Results indicate potential success of future programs covering this topic, but that this brief program was not sufficient to significantly increase knowledge ratings. This study provides evidence that caregivers can benefit from group education programs to address sensory processing. For occupational therapists specifically, findings suggest the need for consistent provision of education and resources regarding sensory processing. 2 A Group-Based Education Program for Caregivers of Children with Sensory Processing Dysfunction Introduction North Shore Pediatric Therapy (NSPT) is a therapy network operated through several centers in the Chicagoland area. Their mission statement is to experience the joy of bringing happiness into the lives of children and their families. In the NSPT system, they offer neuropsychology diagnostics, applied behavioral analysis (ABA), occupational therapy (OT), physical therapy (PT), speech therapy (SLP), mental health services, social work, and early intervention. My project took place at the Lincolnwood location, where my site mentor was a treating OT, as well as the OT Clinical Supervisor and OT team lead. The center director and therapists at this site identified children with sensory processing dysfunction as a population that need support in order to have success in caregiver interactions and in the home environment due to a lack of understanding of sensory processing dysfunction in public knowledge. The research also supported the success of caregiver education in improving family interactions and participation of children with sensory processing difficulties. This doctoral capstone project consisted of a six-week caregiver education group program focused on understanding sensory dysfunction, behavioral responses to sensory stimuli, and sensory strategies and behavior management in the home. The goal of this project was to reduce caregiver strain and increase caregiver understanding of sensory processing dysfunction. Background At the Lincolnwood center, on average, clients ranged from 3 to 12 years old and were often from families with many children. The OT team lead observed that clients from these larger families did not get as much one-on-one attention from caregivers and were less likely to have a 3 lot of room to play due to the urban setting. Caregivers were more likely to do things for their child rather than let them struggle through it and others may attribute difficulties to bad behavior rather than to sensory dysfunction. Common diagnoses for children experiencing sensory processing dysfunction who received services at this site were autism spectrum disorder, disorders of psychological development, lack of coordination, specific developmental disorder of motor function, and delayed milestone in childhood. Caregivers of these children often reported difficulty with constipation, feeding, meltdowns, loud noises, poor body awareness, clumsiness, hyperactivity, and difficulty getting dressed in the morning. Stakeholders at NSPT, such as the OT team lead and other core therapists, determined that caregivers of children with sensory processing dysfunction often struggle to understand what their children are experiencing, which can lead to negative behavioral responses and caregiver strain. There were no other types of sensory education provided to caregivers or employees at this site or in the surrounding community. For educational programs in the past at this site, there was consistent interest from and attendance by caregivers. After thorough search of the literature, the current state of evidence presented a need for this type of educational program. Suzuki et al. (2018) found that support for caregivers of children with autism must address sensory processing dysfunction, as it impacted other symptoms that the children may be experiencing. In support of this, when surveyed, parents living with children with autism identified five topics that they found unclear, three of which were sensory integration, sensory development, and general information on behavioral management strategies (Preece et al., 2017). It was crucial that caregivers were offered information on this topic. Zheng et al. (2019) established sensory sensitivity and its resulting problematic behaviors as causes of maternal stress for mothers of children with autism. Similarly, Kirby et al. (2019) 4 found long-term correlations between a childs sensory processing and activity participation and strain on caregivers, calling for a family-centered approach in order to address both child and caregiver needs. DaLomba et al. (2017) found that parent stress is increased when they cannot engage in occupations due to a childs behaviors and that parents found internalizing sensory behaviors the most stress-inducing. Parents of children with more severe sensory processing difficulties were found to experience more stress in general and this parenting stress can lead to increased discipline and further behavioral problems (Chiang et al., 2019; Suzuki et al., 2018). Thus, the literature established sensory processing dysfunction and resulting issues as causes of caregiver stress and strain. One way this stress in caregivers was addressed was through education. Educational programs, even when completed quickly, resulted in positive outcomes in both behaviors in children with sensory integration challenges and stress in their parents and have been found to encourage parents to participate and seek support (Evatt et al., 2022; Pashazadeh et al., 2019; Miller-Kuhaneck & Watling, 2018). Evidence suggested that parent-focused interventions positively impact their stress and sense of competence by increasing parental knowledge, understanding of sensory processing difficulties, and self-efficacy through education (Allen et al., 2021; Heyburn et al., 2022). The goal of these educational programs was to increase caregivers abilities to anticipate sensory triggers and therefore decrease behavior disturbances (Fletcher et al., 2019). Sensory sensitivity affected attachment styles and the parent-child relationship, requiring a parent to know their own level of sensory sensitivity and gain awareness of how that affects their interactions with their child (Branjerdporn et al., 2019; Chang et al., 2018). Davis et al. (2017) found that parental instruction and education improve enforcement and compliance to sensory programs at home and school. A group education protocol executed by 5 Gee & Peterson (2016) was effective in increasing knowledge of sensory processing dysfunction, as well as caregivers perceived competence in managing sensory behaviors. This program was the first of its kind in the area to address this population and aim to decrease caregiver strain. The group conducted at NSPT was informed by a thorough literature search of recommendations for group structure, content, and methods, as well as the specific, unique wants and needs of participants and the community. Education and support were approached through the lens of Kuhaneck & Watling (2015). Theory and Frame of Reference This project was guided by the PEO model of occupational performance. This model defines the three domains of Person, Environment, and Occupation and describes successful engagement as an optimal Fit between the three (Cole & Tufano, 2020). The Person is a unique being with many roles (Cole & Tufano, 2020). The Person for my project was twofold: both children with sensory dysfunction and their caregivers. For each, their behaviors, actions, and sensory characteristics were unique to them and affected their engagement. The Environment is cultural, socioeconomic, institutional, physical, and social environments in which the Person lives and engages (Cole & Tufano, 2020). For the clients at my DCE site and their caregivers, the Environment was the home, school, the playground, the dinner table, and anywhere else the caregiver and child were interacting and engaging in occupations. The Environment for these individuals also included the sensory feedback that is being provided by the environment. Finally, Occupation is defined as self-directed, meaningful tasks (Cole & Tufano, 2020). For these participants, the primary Occupations were play, school, self-care, and caregiving. The goal of my project was to increase the Fit between these three to decrease caregiver strain and 6 increase their understanding of sensory processing dysfunction. The Fit was assessed by examining strain and self-efficacy that contribute to performance of caregiver tasks. The frames of reference used to guide my project are sensory integration and applied behavioral. The caregivers participating in my program all cared for children with sensory processing dysfunction. It was important for caregivers to understand these characteristics in order to improve their childs occupational engagement and maintain satisfaction with their role. Sensory disturbances can also lead to behavioral challenges, so the applied behavioral perspective was utilized in order to help caregivers understand how to respond to behaviors. Project Design The goal of this doctoral capstone project was to reduce caregiver strain and increase caregiver understanding of sensory processing dysfunction. The project consisted of a weekly, 30-minute caregiver education group with six total sessions covering different topics. Outcomes were measured formatively via Microsoft Forms before and after participation in the program using scales adapted for this project from Gee & Peterson (2016) (Appendices B & C). Appropriate face validity of these pre- and post-test measures was established by Gee & Peterson (2016), but further reliability has yet to be established. These measures focused on caregiver selfefficacy and knowledge of sensory processing. Sessions were structured as follows: ice breaker activity, review of content from the previous session, presentation of educational content, and wrap-up with Q&A. Groups were intended to occur over twenty to thirty minutes. Due to a high amount of initial interest, two different groups were conducted identically on different days each week to include as many participants as possible. Project Implementation 7 Contact was initiated with participants via email and social media post (Figure 1) on the NSPT Facebook account encouraging caregivers to fill out the linked interest survey. Information about the group was also shared at a local family event by an NSPT employee. All individuals were welcome to attend, including but not limited to parents, childcare professionals, teachers, and healthcare professionals. On the survey, participants indicated whether or not they were able to log onto the virtual group via Zoom, Google Meets, or Microsoft Teams. They then chose what days of the week and times of day that they would be available to attend. The site requested that the survey also ask whether or not their child is currently receiving any services through NSPT, their family name, email, and phone number. Finally, they were asked to note any topics that they were hoping would be covered in the groups. These were included in the presentations as appropriate. Recruitment took place over only one week, which significantly limited the caregivers that were reached. Educational content was centered around topics identified in the literature as needed areas according to caregivers of children with sensory processing difficulties. The group topics were as follows: (1) Understanding sensory processing dysfunction, (2) Abstract sensory systems and sensory processing development, (3) Sensory processing and behavior, (4) Becoming a sensory detective, (5) Caregiver burnout and selfcare, and (6) Social participation, self-care, and red flags. Due to their specialized nature, topics not covered included feeding, sleep, constipation, and school accommodations. All presentations were designed by the capstone student and approved by the site mentor. The education groups began during the fifth week of the capstone experience and occurred twice weekly through the tenth week. Meeting links were sent out to all participants two days before the meetings and the same links were used for each meeting for ease of access. Participants were asked to fill out the pre-test measure via Microsoft Forms before attending 8 their first group session. All presentations were recorded afterward by the capstone student to be shared with anyone who was unable to attend. Participants were encouraged to keep their camera off or change their display name if that made them more comfortable attending the groups. Along with an icebreaker, participants were encouraged to share any sensory wins or sensory successes that they had in their life or in their interactions with their child recently. This was intended to give other participants ideas for strategies they could try with their own child, as well as foster a sense of community within the groups. Participants were also encouraged to contact the student or site mentor at any time with more personal or specific questions. After the final session, caregivers were asked to fill out the post-test survey via Microsoft Forms and were also encouraged to stay in contact with the groups facilitators to share successes and ask questions. During recruitment and implementation, the capstone site moved physical locations. This affected the number of caregivers who might have been reached through physical advertisements in the center. There was also a lack of buy-in for the project from providers at the site, so they did not advertise the group to families with whom they came into contact. This was part of a larger issue surrounding communication between the capstone student and site contacts. Although there was a high level of initial interest in the groups, attendance decreased significantly after the first week of sessions covering general sensory processing information, decreasing the support-group style intended for the groups. Project Outcomes The capstone student removed repetitive questions from the three outcome measures from Gee & Peterson (2016) and combined them into one short survey. In the survey displayed in Appendix A, participants were asked to rate their knowledge of each group topic on a sevenpoint Likert scale, with (1) indicating I dont know anything about the topic, and (7) indicating 9 I have an excellent understanding and am comfortable sharing my knowledge with others. Next, in the section displayed in Appendix B, they were asked to rate their confidence in managing sensory processing difficulties from (1), Not at all confident, to (7), Very confident and their satisfaction with their current management strategies from (1), Not satisfied at all, to (7), Very satisfied. Participants were also asked to rate how difficult they found it to manage the sensory related behaviors of their children from (1), Very difficult, to (7), Not at all difficult, and the extent to which their felt they had a positive effect on their childs sensory processing difficulties from (1), Has no positive effect at all, to (7), Has a very positive effect. Finally, they were asked to note any topics they wanted to learn more about, describe their perceptions of their child's behaviors, play preferences, and self-help skills (Appendix B). The information from the final, written questions was used to develop session content and resource provision. More caregivers (N=17) completed the pre-test survey than actually attended the groups consistently or responded to the post-test survey. Although the majority of the caregivers who reported that their child had received OT services (n=14) (Figure 2), few of the participants that consistently attended sessions (i.e., attended more than one) reported that their child had received OT services (n=2). At this site, this seemed to indicate a lack of referrals to OT from other disciplines and a lack of sensory education being provided by other therapists. Participants reported that their children were very active and playful, but often seemed like they were not aware of safety or their surroundings. Many reported that their child struggled with touch and noise and often showed outward signs of their sensory overload or dysregulation. When this occurred, participants noted that their children often did not know how to manage it themselves and it frequently manifested as aggression. 10 The variables displayed in Figure 3 were identified from current research surrounding this topic (Gee & Peterson, 2016). As seen in Figure 3, initial levels of self-efficacy aligned with the findings of Gee & Peterson (2016), indicating that the majority of caregivers of children with sensory processing difficulties did not feel that they had effective strategies to manage sensoryrelated behaviors. Caregivers reported on the pre-test measure that they found it very difficult to deal with the challenges of the child that they cared for. However, the majority of caregivers also reported that they felt their current management had a positive effect, even before participation in the educations sections. A paired two-sample -test was run to compare pre- and post-test knowledge scores by topic, but results were statistically insignificant, as expected for a small sample size. Still, as shown in Figure 4, the average post-test knowledge score for each topic, many of which were identified as areas in need of improvement by caregivers (Preece et al., 2017) were notably higher than on the pre-test. This is encouraging because it aligns with the current research, suggesting that participation in education groups like these can be an effective manner of improving caregiver knowledge of this topic (Allen et al., 2021). Positive outcomes like these indicate a potential decrease in caregiver strain related to increased knowledge and understanding in caregivers (Miller-Kuhaneck & Watling, 2018). Participants were encouraged to seek extra resources and continue applying what they learned from the sessions, and it is expected that, if surveyed again, their knowledge scores would increase further (Evatt et al., 2022). Caregivers also reported that they felt they learned about many of the topics that were previously unclear to them, meeting a present demand in the community (Heyburn et al., 2022). Summary 11 Stakeholders at NSPT identified caregivers of children with sensory processing dysfunction as a population that needed support. My DCE project consisted of a six-week caregiver education group program focused on understanding sensory dysfunction, behavioral responses to sensory stimuli, and sensory strategies, as well as caregiver burnout and self-care. The goal of this project was to reduce caregiver strain and increase caregiver understanding of sensory processing dysfunction. This program was the first of its kind in this community. The literature supported this type of educational program focused on sensory processing and related topics as a manner of reducing caregiver stress and strain. Kirby et al. (2019) found long-term correlations between a childs sensory processing, activity participation, and strain on caregivers, calling for a family-centered approach in order to address both child and caregiver needs. Evatt et al. (2022) suggest that OTs measure and address caregiver stress through education and support groups. Studies found that educational programs result in positive outcomes for stress in parents, behavioral issues, self-efficacy and self-confidence, and supportseeking by caregivers (Allen et al., 2021; Gee & Peterson, 2016; Heyburn, et al., 2022; MillerKuhaneck & Watling, 2018; Pashazadeh et al., 2019). Unfortunately, few of the participants that consistently attended sessions reported that their child received OT services. This functions both as an indication of insufficient referrals to OT by other disciplines in this system and to explain why caregivers may not feel like they have effective strategies to manage these behaviors at home. Levels of self-efficacy aligned with previous research findings, with the majority of caregivers reporting that they did not feel that they had effective strategies to manage sensory-related behaviors. Knowledge scores for each topic increased from pre- to post-test, indicating an increase in understanding of each topic on average across all participants. 12 Conclusion The results of this unique program indicate positive potential for success of future programs of the same design or addressing the same topic and population. This study aligned with the literature supporting reduction of caregiver strain and increase of understanding through targeted group education programs. Unfortunately, it also showed that even six sessions were not sufficient to produce statistically significant differences in knowledge ratings. As a benefit to NSPT in particular, this program increased caregivers awareness of their childs need for OT services while increasing access to resources for individuals with sensory processing dysfunction in this community. This program also provides a framework for recruitment and application of group education that programs of this type could utilize to be successful in this community in the future. This study provides evidence that caregivers can benefit from programs of this type in the future to address different topics of their concern. One potential issue with this is the busy nature of this particular population in their role as caregivers. For OTs specifically, these findings suggest the need for constant caregiver education and provision of resources, including encouraging caregivers to observe sessions and explaining sensory preferences and strategies that are present with their child. Providers should not be waiting for caregivers to ask for the information before giving it. 13 References Allen, S., Knott, F.J., Branson, A., & Lane, S.J. (2021). Coaching Parents of Children with Sensory Integration Difficulties: A Scoping Review. Occupational Therapy International, 111. https://doi.org/10.1155/2021/6662724 Branjerdporn, G., Meredith, P., Strong, J., & Green, M. (2019). Sensory sensitivity and its relationship with adult attachment and parenting styles. PLoS ONE, 14(1). https://doi.org/10.1371/journal.pone.0209555 Chang, M., Burr, A., Staffaroni, G., Adams, M., Gines, C., & Crawford, J. (2018). Stress, Sleep, and Sensory Processing Among Parents of Children with Autism Spectrum Disorder...AOTA Annual Conference & Expo, April 19 to April 22, 2018, Salt Lake City, Utah. American Journal of Occupational Therapy, 72, 1. https://doi.org/10.5014/ajot.2018.72S1-PO6019 Chiang, W.-C., Tseng, M.-H., Fu, C.-P., Chuang, I.-C., Lu, L., & Shieh, J.-Y. (2019). Exploring sensory processing dysfunction, parenting stress, and problem behaviors in children with autism spectrum disorder. American Journal of Occupational Therapy, 73(1), 110. https://doi.org/10.5014/ajot.2019.027607 Cole, M. & Tufano, R. (2020). Applied theories in occupational therapy: A practical approach. (2nd Ed.). Thorofare, N.J.: SLACK Inc Cunliffe, L., Coulthard, H., & Williamson, I. R. (2022). The lived experience of parenting a child with sensory sensitivity and picky eating. Maternal & Child Nutrition, 18(3), 111. https://doi.org/10.1111/mcn.13330 DaLomba, E., Baxter, M.F., Fingerhut, P., & ODonnell, A. (2017). The Effects of Sensory Processing and Behavior of Toddlers on Parent Participation: A Pilot Study. Journal of 14 Occupational Therapy, Schools & Early Intervention, 10(1), 2739. https://doi.org/10.1080/19411243.2016.1257968 Davis, T., Columna, L., Abdo, A. L., Russo, N., Toole, K., & Norris, M. L. (2017). Sensory Motor Activities Training for Families of Children with Autism Spectrum Disorders. Palaestra, 31(4), 3540. Evatt, K. S., Watson, J., & Smith, R. A. (2022). OTs Approach to Caregiver Stress in Parents of Children with Sensory Dysfunction...American Occupational Therapy Association, INSPIRE Conference, March 31-April 3, 2022, San Antonio, Texas. American Journal of Occupational Therapy, 76, 1. https://doi.org/10.5014/ajot.2022.76S1-PO186 Fletcher, T., Anderson, S. J., Wagner, H., Linyard, M., & Nicolette, E. (2019). Caregivers perceptions of barriers and supports for children with sensory processing disorders. Australian Occupational Therapy Journal, 66(5), 617626. https://doi.org/10.1111/14401630.12601 Gee, B.M., & Peterson, T.W. (2016). Changes in Caregiver Knowledge and Perceived Competency Following Group Education about Sensory Processing Disturbances: An Exploratory Study. Occupational Therapy International, 23(4), 338345. https://doi.org/10.1002/oti.1435 Heyburn, K., Shaw, D., Carbert, K., & Thompson-Hodgetts, S. (2022). Sensory In-Service: An Exploratory Evaluation of a Group-Based, Caregiver Intervention for Children with Sensory Processing Difficulties. Physical & Occupational Therapy in Pediatrics, 115. https://doi.org/10.1080/01942638.2022.2104151 Kirby, A.V., Williams, K.L., Watson, L.R., Sideris, J., Bulluck, J., & Baranek, G.T. (2019). Sensory features and family functioning in families of children with autism and 15 developmental disabilities: Longitudinal associations. American Journal of Occupational Therapy, 73(2), 114. https://doi.org/10.5014/ajot.2018.027391 Kuhaneck, H. M., & Watling, R. (2015). Occupational therapy: Meeting the needs of families of people with autism spectrum disorder. American Journal of Occupational Therapy, 69(5), p1p5. https://doi.org/10.5014/ajot.2015.019562 Miller-Kuhaneck, H., & Watling, R. (2018). Parental or teacher education and coaching to support function and participation of children and youth with sensory processing and sensory integration challenges: A systematic review. American Journal of Occupational Therapy, 72(1). http://dx.doi.org/10.5014/ajot.2018.029017 Pashazadeh Azari, Z., Hosseini, S.A., Rassafiani, M., Samadi, S.A., Hoseinzadeh, S., & Dunn, W. (2019). Contextual Intervention Adapted for Autism Spectrum Disorder: An RCT of a Parenting Program with Parents of Children Diagnosed with Autism Spectrum Disorder (ASD). Iranian Journal of Child Neurology, 13(4), 1935. Preece, D., Symeou, L., Stoic, J., Troshanska, J., Mavrou, K., Theodorou, E., & Frey krinjar, J. (2017). Accessing Parental Perspectives to Inform the Development of Parent Training in Autism in South-Eastern Europe. European Journal of Special Needs Education, 32(2), 252269. http://dx.doi.org/10.1080/08856257.2016.1223399 Suzuki, K., Takagai, S., Tsujii, M., Ito, H., Nishimura, T., & Tsuchiya, K. J. (2019). Sensory processing in children with autism spectrum disorder and the mental health of primary caregivers. Brain & Development, 41(4), 341351. https://doi.org/10.1016/j.braindev.2018.11.005 16 Zheng, L., Grove, R., & Eapen, V. (2019). Predictors of maternal stress in pre-school and schoolaged children with autism. Journal of Intellectual & Developmental Disability, 44(2), 202211. https://doi.org/10.3109/13668250.2017.1374931 17 Figures Figure 1 Recruitment Flyer and Email Distributed to NSPT Community Figure 2 Current Therapy Services Received by Children of Participants Figure 3 Participants Pre-Test Ratings of Identified Variables 18 Participants Pre-Test Ratings of Identified Variables To what extent do you feel in control of the challenging sensory related behaviors of the child/children you care for? How satisfied are you with the way in which you deal with the challenging sensory related behaviors of the child/children you care for? 1 2 3 To what extent do you feel that the way you deal with the challenging sensory related behaviors of the child/children you care for has a positive effect? 4 5 How difficult do you personally find it to deal with the challenging sensory related behaviors of the child/children you care for? 6 7 How confident are you in dealing with the challenging sensory related behaviors of the child/children you care for? -100% -75% -50% -25% 0% 25% 50% 75% 100% Figure 4 Knowledge/Understanding by Topic Before and After Educational Sessions Knowledge/Understanding by Topic Before and After Educational Sessions Self-care and executive functioning Caregiver burnout Determining sensory needs or causes of behaviors Behavioral responses to sensory dysfunction Sensory development Sensory processing dysfunction 1 Average post-test score 2 3 4 Average pre-test score 5 6 7 (Modified from Gee & Peterson, 2016) 19 Appendix A: Pre/Post Questionnaire Please fill out this questionnaire as thoroughly as possible. You will either be filling this out prior to starting a group or as your completing the seventh session of the play group. Name or email: ____________________________ Todays Date: ______________________ When are you completing this survey? a. Before the group b. After the group 1. What current therapy services does your child receive (circle all that apply)? a. Occupational Therapy b. Physical Therapy c. Speech Therapy d. Advanced Behavioral Analysis (ABA) e. None f. Other (Please specify): ___________________________________ 2. How would you rate your knowledge/understanding of the following sensory processing concepts (please circle one number for each question)? 1. Sensory dysfunction 2. Sensory development (Modified from Gee & Peterson, 2016) 20 3. Behavioral responses to sensory dysfunction 4. Determining sensory needs or causes of behaviors 5. Caregiver burnout 6. Self-care and executive functioning 3. Please provide any additional comments or feedback regarding the handouts, the group, activities, etc. (post group). 4. Please comment on your perceptions of your childs behaviors, play preferences, and self-help skills. 21 (Modified from Gee & Peterson, 2016) Appendix B: Caregiver Self Efficacy with Sensory Related Behavior Below are several questions that ask about your responses to challenging sensory related behaviors displayed by the child or children you care for. Please read each question and place a circle around the number on the scale that reflects your own views. If your views are described best by the end points of the scale, please circle either number 1 or number 7. If your views are somewhere in between the two end points, please select a position on the scale that reflects where you feel your views should be placed. Please select a response for all of the questions. How confident are you in dealing with the challenging sensory related behaviors of the child/children you care for? 1 2 3 4 5 6 Not at all confident 7 Very confident How difficult do you personally find it to deal with the challenging sensory related behaviors of the child/children you care for? 1 2 3 4 5 6 Very difficult 7 Not at all difficult To what extent do you feel that the way you deal with the challenging sensory related behaviors of the child/children you care for has a positive effect? 1 2 3 4 5 6 7 22 (Modified from Gee & Peterson, 2016) Has no positive effect at all Has a very positive effect How satisfied are you with the way in which you deal with the challenging sensory related behaviors of the child/children you care for? 1 2 3 4 5 6 Not satisfied at all 7 Very satisfied To what extent do you feel in control of the challenging sensory related behaviors of the child/children you care for? 1 2 Not in control at all 3 4 5 6 7 Very much in control 23 Appendix C: Weekly Planning Guide Week DCE Stage 1 Orientation Weekly Goal 1. Complete orientation by the end of the week Objectives - Meet with site mentor, tour site, discuss plan of action for next 14 weeks. - Plan remote/in-person schedule for coming week. Tasks - Complete Weekly Planning Guide - Fill out weeks calendar. - Finalize MOU and goals. - Pull important points from - Revisit literature review, literature review, needs needs assessment, and assessment, and MOU. MOU. - Understand site policies, expectations. - Write proposal planning timeline - Develop recruitment - Contact NSPT materials administrator with group questions 2. Observe sessions - Grow familiarity with caseload, common treatments, common diagnoses. - Observe ABA sessions - Observe on-site for 1 full day and 2 half days this week Due Date 1/13 24 2 Screening/Evaluation 1. Search for new literature to strengthen literature review. 2. Establish 6 topics for 6 sessions of group. 3. Gather information of what should be included in ABA educational materials - Pull key articles from literature review. - Review research databases and AOTA - Organize literature. - Organize Zotero folders - Find new, related literature for session planning. - Write down key points from new literature - Pull topic ideas from literature - Group topics into 6 sessions - Begin loose outlines of sessions - Ice breaker activity, reviewing previous sessions, presentation of educational content, and wrap-up with Q&A - Send interest poll - Determine appropriate time and delivery method for groups - Observe at least 1 ABA practitioner - Interview ABA practitioners about questions they have - Interview therapy practitioners about what they wish ABA technicians knew - Familiarize myself with existing goals in goal bank 1/20 25 3 4. Begin researching sensory goals and insurance Screening/Evaluation 1. Design week #1 presentation and content - Gain awareness of insurance coverage and sensory treatment codes - Prepare presentation - Contact insurance companies if necessary - Organize topics 1/27 - Write presenter notes - Practice delivery - Adapt pre-test measures to project 2. Design week #2 presentation and content 4 3. Introduction draft due Screening/Evaluation 1. Finalize weeks #1 and 2 of sensory education group - Prepare presentation - Organize topics - Write presenter notes - Prepare presentation - Practice delivery - Ask caregivers to list anything they want to make sure is covered in the groups 2. Begin compiling parent interest survey responses - Get feedback from site mentor and practice audience - Rehearse twice 3. Create caregiver resources - Common topics requested from past clients and in interest survey - Adjust according to feedback - Adjust according to feedback 2/3 26 4. Background draft due 5 (Group week #1) Implementation 5. Conclude collection of ABA information - Gather common responses to practitioner poll 6. Meet with Clinic Director 1. Conduct week #1 of sensory education group - Gather any other thoughts from BCBAs/core therapies - Conduct 45-50 min session with extra time for questions/support - Separate responses by common theme - Organize themes into topics - Distribute pre-test - Provide resources based on week #1 topic - Record session for those who cannot attend 2. Follow up with caregivers - Provide resources 3. Prepare for week #2 group - Prepare presentation - Practice delivery 4. Design week #3 presentation and content - Prepare presentation - Organize topics 5. Project design draft due - Gather feedback - Send recording and resources - Write presenter notes 2/10 27 6. Analyze NSPT goal banks - What sensory goals already exist? Are there gaps? - How are goals structured? 6 (Group week #2) Implementation - Edit existing goals - Gather feedback on what is needed - Draft 3 example goals for feedback - Provide resources based on week #2 topic 1. Conduct week #2 of sensory education group - Conduct 45-50 min session with extra time for questions/support 2. Follow up with caregivers - Provide resources 3. Prepare for week #3 group - Prepare presentation - Practice delivery 4. Design week #4 presentation and content - Prepare presentation - Organize topics 5. Analyze NSPT goal banks - Complete updates to sensory goal bank - Gather feedback - Record session for those who cannot attend - Send recording and resources - Write presenter notes - Remove sensory language - More than just tolerance goals - At least 4 caregiverinvolved goals 2/17 28 7 (Group week #3) Implementation 1. Conduct week #3 of sensory education group - Conduct 45-50 min session with extra time for questions/support - Provide resources based on week #3 topic 2. Follow up with caregivers - Provide resources - Send recording and resources 3. Prepare for week #4 group - Prepare presentation - Practice delivery 4. Design week #5 presentation and content - Prepare presentation - Organize topics - Gather feedback 2/24 - Record session for those who cannot attend - Write presenter notes 5. Midterm eval due 8 (Group week #4) Implementation 6. Continue working on ABA training update 1. Conduct week #4 of sensory education group - Talk to ACC about topics - Send topics to ACC and mentor for approval - Conduct 45-50 min session with extra time for questions/support - Provide resources based on week #4 topic 2. Follow up with caregivers - Provide resources - Send recording and resources - Gather feedback - Record session for those who cannot attend 3/3 29 3. Prepare for week #5 group - Prepare presentation - Practice delivery 4. Design week #6 presentation and content - Prepare presentation - Organize topics - Write presenter notes 4. Create ABA training - Base on topics gathered update presentation from polls and interviews 9 (Group week #5) Implementation 1. Conduct week #5 of sensory education group - Contact ACCs from other clinic for information and collaboration - Conduct 45-50 min session with extra time for questions/support 2. Follow up with caregivers - Provide resources 3. Continue updating ABA training with sensory information - Provide examples of safe and unsafe behavior - Gather feedback - Borrow relevant information from caregiver presentations - Provide resources based on week #5 topic - Record session for those who cannot attend - Send recording and resources - Share with site mentor for feedback 3/10 30 - Advise on interprofessional communication 5. Methods draft due 10 (Group week #6) Implementation 1. Conduct week #6 of sensory education group - Postponed due to delayed post-test data collection - Conduct 45-50 min session with extra time for questions/support - Meet with ACCs to learn about other updates to BT training - Provide resources and send recording - Distribute post-test measure - Ask for feedback 2. Send ABA content for corrections and comments - Share with multiple disciplines - Gather feedback 3. Create outcome measure to assess comprehension of topics covered - Create fill-in-the-blank worksheet 3/17 4. Complete dissemination plan 11 Discontinuation 5. Draft of outcomes due to mentor 1. Dissemination plan due 2. Analyze outcomes 3/24 - Input data into spreadsheet 31 - Compare pre- and posttest scores 3. Reflect on project 12 13 (Last week at NSPT) Discontinuation Dissemination - Significant differences preand post? - Compile written feedback - Write list of recommendations, favorite parts, etc. - Successes? Failures? Practical considerations? - Compare parent feedback, therapist feedback, stakeholder feedback 4. Write outcomes, results, and findings 1. Work on outcomes section 3/31 2. Assess improvements to project in future - How would I fix the recommendations? - Are they feasible? - Do I have anything I would want to change? - Plan for updating with new literature, new needs 3. Send sensory goals for review 1. Make plan for continuation of project at site - Send to Monica for feedback - Contact UIndy student - Correct according to any feedback - Ask for plan - Is there a therapist there who would like to continue? - What materials would she like to use? - Marketing 4/7 32 2. Design presentation for stakeholders - Highlight how this brings business to NSPT - Most of the work is already done 3. Finalize outcomes section based on feedback 4. Last week onsite 14 (Monica OOO) Dissemination 1. Disseminate results to site stakeholders 2. Draft of abstract, summary, and conclusion due - Explain goals of program based on results of needs assessment - Highlight successes and potential for future, wide implementation 4/14  ...

... Developing Mental Health Resources for Clinicians and Caregivers of Patients with an Acquired Brain Injury Kelsey Smith, OTS May1, 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Jenna Trost, OTD, OTR MENTAL HEALTH RESOURCES 2 Abstract Mental health and psychosocial education were identified as areas that required improvement at Ascension St. Vincent Inpatient Rehabilitation in Evansville Indiana. Through this process, resources for clinicians and caregivers have been developed to encourage conversations about mental health with patients that have experienced an Acquired Brain Injury (ABI). There were four (n=4) patients admitted with an Acquired Brain Injury during the implementation phase of this project. Through the use of the depression screening tool, The Patient Health Questionnaire (PHQ-9), three patients identified feelings of mild to moderate depressive symptoms at admission. Through promoting conversations surrounding mental health, mindfulness activities and the use of cognitive behavioral therapy interventions the patients that indicated mild to moderate symptoms of depression upon admission demonstrated a decrease in scores at discharge. The continued use of the assessment and intervention techniques were recommended to the site to continue addressing mental illness among this specific population. MENTAL HEALTH RESOURCES 3 Introduction Ascension St. Vincent is one of the countrys leading non-profit catholic healthcare networks. The network operates over 2,600 facilities spanning 19 states (Site). While Ascensions services are diverse, its commitment to its community is unwavering. Ascension St. Vincent prides itself on the diversity of care that is offered to a diverse population of patients. The inpatient rehabilitation setting provides services to patients after orthopedic injury, neurological injury, stroke, surgery, or general debility after hospitalization. The Doctoral Capstone Project creates educational binders for clinicians and caregivers of patients with an Acquired Brain Injury (ABI). These resources will adequately address comorbid mental illnesses after experiencing an Acquired Brain Injury (ABI). This binder will also address the literacy concerns of the patient and their caregiver to promote easily understandable material as a way to facilitate the educational understanding of the importance of mental health education for caregivers. Through skill development and project implementation, the mental health educational binder will be implemented in the inpatient rehabilitation unit at Ascension St. Vincent in Evansville, Indiana. These binders will serve as a tool for clinicians and caregivers to address the stigma around mental health best. In addition, education about comorbid mental illnesses will allow the caregiver and the patients to understand the changes in the brain after brain injury and various ways to combat their symptoms. Most caregivers do not receive proper mental health education or support due to the sudden onset of the injury or condition of their loved ones. Especially given the nature of an acquired brain injury. It is essential to understand the benefit of providing mental health education to caregivers of those with an acquired brain injury to reduce risk of caregiver burnout and mental illness. MENTAL HEALTH RESOURCES 4 Background A brain injury takes a physical, mental, emotional, and financial toll on a persons overall well-being. Transitioning from functionally independent to predominantly dependent creates an internal struggle among patients. This can then lead to the development of psychological disorders in effort to cope with the new reality. The most prevalent comorbid diagnoses are Depression, Anxiety, and substance use disorder (Marinkovic et al., 2017, Yeh et al., 2020). One study has identified that one out of every four persons with a brain injury has a psychiatric disorder to accompany their Traumatic Brain Injury diagnosis (Marinkovic et al., 2017). The immediate ramifications of an acquired brain injury are not always present, and the onset can take anywhere from 1 week to a few years after injury. Specific behaviors may develop later in the patients rehabilitation due to the alteration in brain function, which can create personality discrepancies that inhibit occupational performance and participation throughout the remainder of the lifespan. One study acknowledges the prevalence of anxiety, depression, and substance use disorder in patients with TBI and implements various interventions in the rehabilitation process to prevent the further development of a psychiatric disorder (Rauwenhoff et al., 2019). Currently, the hospital provides binders to the patients about specific diagnoses (CVA and TBI), which serve as educational tools. This is an interactive binder that allows interprofessional communication between all therapy disciplines to outline the severity of the injury, as well as highlight perceived deficits, goals, and overall progress. Upon completing the Needs Assessment, it was apparent that there were gaps in providing mental health services and education for all patients, specifically patients that have sustained an Acquired Brain Injury (ABI). Through the development of the Doctoral Capstone Project, caregiver education was identified as an area of need. MENTAL HEALTH RESOURCES 5 Through a variety of research studies, it has been shown that the spouse and parents of the injured suffer the most. It is important to note that traumatic experiences are not limited to only the injured person (Tsur & Haller, 2020). Social support plays a large role in the success of the caregiver. According to Qadeer et al. (2017), caregivers with minimal social support were more at risk of developing psychological discontent. This can then develop into depression, anxiety, or substance use disorder. Furthermore, caregivers taking care of a person with a brain injury and substance use disorder (SUD) are at an even higher risk of developing their own psychological issues due to increased stress (Qadeer et al., 2017). Specific behaviors may develop in the patient due to altered brain function, which can create hostility, aggression, and irritability. This makes caregiving quite challenging due to the potential for mental and verbal abuse. In addition to the verbal and mental abuse, the caregiver could be sustaining the abrupt change in personality due to the injury is often hard to cope with, leading to poor coping skills among caregivers. The carryover of mental illness between caregiver and patient is reciprocal in nature. One study has found that a patient with lower life satisfaction has a caregiver with lower life satisfaction (Qadeer et al., 2017). Unfortunately, few studies have accurately identified the exact number of caregivers that have developed a mental illness after a significant amount of time spent caring for a person with a brain injury. Due to the sudden nature of brain injuries, it is tough to focus solely on the caregiver. In contrast, a person with a brain injury needs extensive care to increase function and independence. The care for the caregiver and the patient must include the entire family. Singling out the patient or the caregiver will create miscommunication between the patient and their caregiver. By identifying areas in which the caregiver is struggling MENTAL HEALTH RESOURCES 6 mentally, the patient can create a plan of care that addresses the needs of each person involved (Devi et al., 2020). Some caregivers can experience Post-Traumatic Stress due to the injury their loved one has endured (Tsur & Haller, 2020). The financial burden healthcare expenses put on a family can create a great deal of stress for the caregiver, especially when their loved one was the person that took care of the familys financial expenses. General life participation has become dramatically different, and the routine of the patient and their caregiver is also changed. The feelings of burnout begin to weigh on a person when they have not been recognized for the sacrifices that are made to ensure the patients needs are met. Future research can also address the coping mechanisms most common in caregivers and provide educational materials for caregivers to incorporate to better cope with the stress of their job. Addressing the needs of both the patient and their caregiver can create unity and elevate the quality of care being provided. Through analysis of current literature, caregiving, and mental health at the Inpatient Rehabilitation level are often overlooked as there are many other pressing issues, like physical rehabilitation. This project will create a vessel to address caregiver mental health at the inpatient rehabilitation level, as this allows preparation for a safe and educated discharge plan. Theoretical Framework The Canadian Model of Occupational Performance and Engagement (CMOP-E) will be used as the occupation-based model. CMOP-E addresses the needs and capabilities of a person and makes adaptations to promote functionality and independence. By keeping the client at the center of the rehabilitation process, practitioners are able to address the areas in their lives creating dysfunction (Polatajko et al., 2007). The CMOP-E implements client-centered care while addressing mental health after a brain injury. This project will focus on increasing MENTAL HEALTH RESOURCES 7 clinicians and caregivers understanding of mental illness in order to improve the overall mental health of the patients. This project will promote engagement and occupational performance through the use of open dialogue, mindfulness-based activities and cognitive behavioral therapy interventions allowing the patients to identify areas they feel they are being challenged. CMOP-E encapsulates the person as a whole and the internal and external influences that shape the human experience, all while keeping the human spirit at the center of the model. The Frame of reference that will guide the capstone experience is Cognitive Behavioral Theory. Cognitive Behavioral Theory facilitates change by changing the thought patterns, behaviors, and feelings toward specific events in ones life. The use of cognitive behavioral theory will facilitate the patients ability to use diverse cognitive processes, and help the client develop accurate self-awareness and realistic perceptions of others and the environment by providing tools and education for the client. This theory allows individuals to control and manage their own thoughts, feelings, and behavior to cope with stress, manage time, and balance their life roles and occupations (Cole & Tufano, 2020). This project is working toward facilitating a space where the client is able to express their concerns about potential mental illness while equipping clinicians and caregivers with tools to properly address mental health concerns. Project Design and Implementation This Project aims to increase mental health awareness and education in the inpatient rehabilitation setting for clinicians and caregivers of patients that have experienced an Acquired Brain Injury (ABI). Through the Needs Assessment, it was disclosed that very little mental health education is provided for patients and their caregivers during their stay in inpatient rehabilitation. To ensure that mental health is being addressed by the staff members, an educational resource binder will be created. In addition to the resource binder for the staff MENTAL HEALTH RESOURCES 8 members, a mental health resource binder will be created for patients with Acquired Brain Injuries and their caregivers to increase the carryover after discharge. The role of an occupational therapist in the inpatient rehab setting includes evaluating the patients current level of function, establishing goals, providing skilled treatment, and generate safe discharge plans for the patient. Depending on the required services, patients can spend anywhere from one hour to ninety minutes with the therapist per day. Clinicians are able to develop rapport with the patient quite easily as they are working closely with each other every day. Being able to discuss mental illness with patients was viewed as a daunting task when unsure of how to approach the topic. This project aims to equip clinicians with tools and interventions that promote mental well-being while completing other meaningful treatments. The resources created can be used by all disciplines (occupational therapy, physical therapy and speech therapy). An educational in-service was provided for staff members to ensure understanding of the binder and the resources that have been included. Through conversating with various clinicians it was disclosed that many felt unequipped to discuss mental illness with patients and their caregivers. Of the three disorders, many clinicians identified feeling least comfortable discussing substance use disorder with patients and their caregivers. The binder provides various factsheet handouts, various assessment tools, intervention ideas, as well as conversation guides. In order to best address mental health concerns among patients with Brain Injuries, it is essential to provide educational resources to the staff members that will be working closely with the patients. The contents of the binder include various cognitive behavioral therapy activities, mindfulness activities, conversation guides, various assessment tools and informational handouts that can be given to patients or their family members. Currently, there are very few resources. The project MENTAL HEALTH RESOURCES 9 aims to create a space for rehab staff to expand their knowledge on the topic of mental health as it relates to ABI. The project consists of administering the PHQ-9, which is a depression screening tool used to identify signs and symptoms of depression. The PHQ-9 will be administered at admission and discharge to identify the change in symptoms. Patients that were admitted with an ABI diagnosis were required to complete the PHQ-9 within 3 days of admission and were required to complete again on the day of discharge. The results of the PHQ-9 will identify which patients would benefit from increased education and further interventions. This also provides an outline for the resource binder and provide potential assessments and intervention strategies to use when addressing mental health with the patients. At this site, the caregivers of patients that were discharging home were required to attend a family training session as well as a family conference to outline the progression of the patient and future recommendations. During this session, the contents of the CVA/TBI binders as well as the caregiver support binder were discussed with the caregiver and allowed open dialogue between the clinicians, patients and their family members. The contents of the caregiver binder include resources on how to identify symptoms of depression, anxiety, and substance use disorder in patients with an acquired brain injury. The binder includes factsheets about acquired brain injury as well as changes to expect after injury. Project Outcomes Patients that were admitted to the site with a diagnosis of ABI were initially included for participation in the PHQ-9 administration process. The patients were assessed for cognition and communication deficits in the patients initial occupational therapy evaluation to assess the MENTAL HEALTH RESOURCES 10 patients ability to answer questions on PHQ-9 appropriately. Through this process, two patients were excluded from participating as there were severe cognitive deficits inhibiting their ability to complete the screen. The assessment tool that was used in this project was the Patient Health Questionnaire (PHQ-9), which is a short screening tool used to quantify depressive symptoms a patient is experiencing. The PHQ-9 consists of nine questions self-reported screening that requires patients to rate severity of symptoms from 0 (not at all) to 3 (nearly every day). The patients were provided paper copies of the PHQ-9 and completed through self-report. The scores were then taken and calculated. A score of 0-4 indicates minimal or no depressive symptoms, 5-9 indicates mild symptoms, 10-14 indicates moderate symptoms, 15-19 indicate moderately severe, and a score of 20-17 indicate severe depressive symptoms. There were four (n=4) patients admitted with an ABI that were appropriate to complete the PHQ-9 process during this experience. Three of the participants were male and one participant was female. All participants were over the age of 50. During the initial administration of the PHQ-9, one patient reported no signs or symptoms of depression, two patients reported mild symptoms of depression, and one patient reported moderate symptoms of depression. The scores were documented in the patients files so each member of the therapy team could access the scores and plan treatment sessions accordingly. Practitioners were notified of the patients that would benefit from further conversations and interventions surrounding mental illness and facilitating treatments to promote healthy coping skills and mindfulness activities. The results are detailed in Table 1. MENTAL HEALTH RESOURCES 11 Summary It has been identified that one out of every four persons with a brain injury has a psychiatric disorder to accompany their Traumatic Brain Injury diagnosis (Marinkovic et al., 2017). Other symptoms of mental illness may develop one week to years after injury, resulting in the inability to be fully addressed during a patients stay in inpatient rehabilitation. By providing resources for clinicians to provide to caregivers, the risk of unprepared caregivers is reduced. During the development of these resources, it was identified through casual interviewing of clinicians that mental health was not being adequately addressed, if addressed at all. The need for mental health resource guides for clinicians was developed in order to create a space for clinicians to feel comfortable with addressing mental health as well as providing certain interventions to promote mental health during practice. The resources for the clinicians included various factsheets that addressed depression, anxiety and substance use disorder as it related to ABI. It also contains assessment tools, conversation guides, mindfulness-based interventions, and cognitive behavioral therapy activities to promote change in thought patterns and healthy coping skills. Clinicians were educated on how to interpret scores of the PHQ-9 and what resources would be appropriate to use. After evaluating the scores of the PHQ-9 there was a decrease in depressive symptoms from admission to discharge among patients with an ABI. The carryover of mental illness between caregiver and patient is reciprocal in nature. One study has found that a patient with lower life satisfaction has a caregiver with lower life satisfaction (Qadeer et al., 2017). The resources for the caregivers included factsheets that outline behavior and psychological changes that may occur after injury, scheduling templates, routine building resources, mental illness factsheets, and caregiver self-care resources to reduce MENTAL HEALTH RESOURCES 12 burnout. Each caregiver will receive a binder at discharge as a way to increase support at time of discharge. Conclusion Through the analysis of the initial Needs Assessment, mental illness was not being addressed with patients. The resource binder for the clinicians specifically outlines tools and the most recent evidence-based practice findings to best inform their practice. The caregiver binder was created to best support both the caregiver and the patient to create an easier discharge. Verbal education was provided for caregivers during the family conference to outline the contents of the binder and answer any questions. The social worker and case manager will continue to administer the PHQ-9 on admission and discharge of every patient that is admitted to inpatient rehabilitation, however this study focused on patients admitted with an ABI. Through the collection of this data the therapists will be able to identify the patients that would benefit from further services and coordinate with case management and social work to appropriately address the areas of depression, anxiety and substance abuse. Future work in this area could consist of creating a caregiver support group to increase support for both the patients and their caregivers in this area. Other research could explore the options of administering the PHQ-9 for the caregiver as well to increase contextual understanding of the overall caregiver well-being during these trying times. MENTAL HEALTH RESOURCES 13 References Adams, D., & Dahdah, M. (2016). Coping and adaptive strategies of traumatic brain injury survivors and primary caregivers. NeuroRehabilitation, 39(2), 223237. https://doi.org/10.3233/NRE-161353 Devi, Y., Khan, S., Rana, P., Dhandapani, M., Ghai, S., Gopichandran, L., & Dhandapani, S. (2020). Cognitive, Behavioral, and Functional Impairments among Traumatic Brain Injury Survivors: Impact on Caregiver Burden. Journal of Neurosciences in Rural Practice, 11(4), 629635. https://doi.org/10.1055/s-0040-1716777 Fann, J.R., Hart, T., Schomer, K.G. (2009) Treatment for depression after traumatic brain injury: A systematic review. Journal of Neurotrauma 26(2383- 2402,) Kamalakannan, S. K., Gudlavalleti, A. S., Murthy Gudlavalleti, V. S., Goenka, S., & Kuper, H. (2015). Challenges in understanding the epidemiology of acquired brain injury in India. Annals of Indian Academy of Neurology, 18(1), 6670. https://doi.org/10.4103/0972-2327.151047 Marinkovic, I., Isokuortti, H., Huovinen, A., Trpeska Marinkovic, D., Mki, K., Nybo, T., Korvenoja, A., Rahul, R., Vataja, R., & Melkas, S. (2020). Prognosis after Mild Traumatic Brain Injury: Influence of Psychiatric Disorders. Brain Sciences (20763425), 10(12), 916. https://doi.org/10.3390/brainsci10120916 National Center for Education Statistics (NCES), (n.d.) The NCES Fast Facts Tool provides quick answers to many education questions (National Center for Education Statistics). Home Page, a part of the U.S. Department of Education. (n.d.). Retrieved April 3, 2022, from https://nces.ed.gov/fastfacts/display.asp?id=69 MENTAL HEALTH RESOURCES 14 Oyesanya, T. O., Loflin, C., Harris, G., & Bettger, J. P. (2021). Just tell me in a simple way: A qualitative study on opportunities to improve the transition from acute hospital care to home from the perspectives of patients with traumatic brain injury, families, and providers. Clinical Rehabilitation, 35(7), 10561072. https://doi.org/10.1177/0269215520988679 Polatajko, H.J., Townsend, E.A. & Craik, J. 2007. Canadian Model of Occupational Performance and Engagement (CMOP-E). In Enabling Occupation II: Advancing an Occupational Therapy Vision of Health, Well-being, & Justice through Occupation. E.A. Townsend & H.J. Polatajko, Eds. Ottawa, ON: CAOT Publications ACE. 22-36. Qadeer A, Khalid U, Amin M, et al. (2017) Caregivers Burden of the Patients With Traumatic Brain Injury. Cureus 9(8): e1590. DOI 10.7759/cureus.1590 Rauwenhoff, J., Peeters, F., Bol, Y., & Van Heugten, C. (2019). The BrainACT study: Acceptance and commitment therapy for depressive and anxiety symptoms following acquired brain injury: study protocol for a randomized controlled trial. Trials, 20(1), 110. https://doi.org/10.1186/s13063-019-3952-9 St. Vincent Evansville - healthcare.ascension.org. (2019). Retrieved April 3, 2022, from https://healthcare.ascension.org/-/media/healthcare/compliancedocuments/indiana/2019-st-vincent-evansville-chna-report.pdf Tezel, N., Umay, E., & akc, A. (2021). Factors affecting the caregiver burden following traumatic brain injury. Gulhane Medical Journal, 63(3), 186192. https://doi.org/10.4274/gulhane.galenos.2021.1460 MENTAL HEALTH RESOURCES Tsur, N., & Haller, C. S. (2020). Physical and Mental Health and Functioning Among Traumatic Brain Injury Close Relatives: The Role of Posttraumatic Stress Symptoms. Family Process, 59(2), 666680. https://doi.org/10.1111/famp.12454 Vaughn, M. G., Salas-Wright, C. P., John, R., Holzer, K. J., Qian, Z., & Veeh, C. (2019). Traumatic Brain Injury and Psychiatric Co-Morbidity in the United States. Psychiatric Quarterly, 90(1), 151158. https://doi.org/10.1007/s11126-018-9617-0 Yeh, T.-C., Chien, W.-C., Chung, C.-H., Liang, C.-S., Chang, H.-A., Kao, Y.-C., Yeh, H.W., Yang, Y.-J., & Tzeng, N.-S. (2020). Psychiatric Disorders After Traumatic Brain Injury: A Nationwide Population-Based Cohort Study and the Effects of Rehabilitation Therapies. Archives of Physical Medicine & Rehabilitation, 101(5), 822831. https://doi.org/10.1016/j.apmr.2019.12.005 15 MENTAL HEALTH RESOURCES Table 1 Patient 1 Patient 2 Patient 3 Patient 4 Admission Score 0 5 7 11 16 Discharge Scores 0 4 3 6 Change in Scores 0 -1 -4 -5 MENTAL HEALTH RESOURCES 17 Appendix A Week DCE Stage Weekly goal(s) Objective(s) 1 Meet with Nichole (site mentor) and the other rehab therapists to introduce myself and my project Meet with Nichole, Maghan, and the other rehab therapists to introduce myself and educate them on why I am here/what I will be doing for the 14 weeks Orientation Complete Site orientation by end of week Update MOU with site mentor, make changes as necessary Tasks Due Date 1/15 Update MOU if necessary Ensure that all orientation paperwork is completed Understand site environment/where to work/dress code/ etc 2 Screening/ Evaluation Find relevant literature for PHQ9 Finding literature to support outcome assessment Finalized MOU (due 1-20) Work with site mentor to determine most sustainable base for project Create detailed plan for project including goals for training and how I plan to complete them Collect literature for staff intervention binder 3 Screening/ Evaluation Update background with most relevant research Create rough outline of project plan how to train staff, how to train caregivers Create plan for addressing mental Work with social worker to introduce PHQ-9 1/22 Writing introduction (due 1-23) and background draft (due 1-30) 1/29 MENTAL HEALTH RESOURCES 4 5 health with patients) Implementation Work with social worker to develop sustainable plan for administration of PHQ-9 with ABI population Implementation Begin Administering PHQ-9(admission and discharge) 18 Collect resources for intervention binder Design/implementation 2/5 draft (due 2/6) Collect resources for intervention binder Meeting with patients and caregivers to facilitate PHQ-9 and caregiver binder 2/12 6 Implementation Continue data collection of PHQ9 (admission and discharge) Gather data while implementing project for staff Meeting with patients and caregivers to facilitate PHQ-9 and caregiver binder 2/19 7 Implementation Continue data collection of PHQ9 (admission and discharge) Implementation Continue data collection of PHQ9 (admission and discharge) Gather data while implementing project for staff Meeting with patients and caregivers to facilitatePHQ-9 and caregiver binder Meeting with patients and caregivers to facilitate PHQ-9 and intervention binder 2/26 8 Complete staff inservice to present clinician binder 9 Implementation Data collection of PHQ-9 (admission and discharge) Gather data while implementing project for staff Provide Inservice for staff members at IPR to implement mental health interventions into practice Gather data while implementing project for staff and caregivers Finalize caregiver resources for binder 10 Implementation Give PHQ-9 to patients and caregivers (admission and discharge) Gather data while implementing project 3/5 Discuss results with Nichole so far, adjust plan if needed Finalize outcome assessment plan Meeting with patients and caregivers to facilitate PHQ-9 and caregiver binder Meeting with patients and caregivers to facilitate PHQ-9 and caregiver binder 3/12 3/19 MENTAL HEALTH RESOURCES 11 12 13 Implementation Continue to administer PHQ-9 to patients and caregivers Terminate PHQ-9 collection at end of week. Discontinuation Begin data analysis 19 Gather all data collected and begin analysis of current admission and discharge scores. Finalize data collection 3/26 allow for any final questions from staff or caregivers collections Analyze outcome assessment results Create dissemination plan Continue to analyze efficacy of training Determine best method Finalize collection for sharing resources of resources and sustainability of project Ensure Sustainability of Discuss with site project mentor for future implementation Discontinuation Final analysis Planning for dissemination of Work on writing up project results Complete work necessary for dissemination 14 Dissemination Ensure Sustainability of project Disseminate findings Wrap-up on site and complete all clinical skills Disseminate Findings to staff therapists and social work to increase carryover after discontinuation 4/2 Continue editing previous drafts Complete writing all results and outcomes 4/9 Finalize dissemination plan Complete and finalize scholarly report, VoiceThread PowerPoint and Poster Presentation Complete dissemination 4/14  ...

... MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS Mental Health Matters Promoting Mental and Emotional Well-being for Justice-Involved Individuals Kayleigh Smith May, 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Dr. Alissia Garabrant, OTD, MS, OTR 1 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS Abstract The United States has the highest rates of incarceration and recidivism in the world, with justice-involved individuals experiencing the effects of occupational deprivation and mental health issues. The purpose of this research was to address the role of occupational therapy with justice-involved individuals within a work release facility. Sixteen responses were gathered from 5 mental health workshops developed from both an occupational therapy and trauma-informed care perspective. Workshops covered various stress management strategies, including stress exploration, relaxation/meditation, goal setting, emotional regulation, and journaling. Pre- and post-survey data was collected to identify changes in participant knowledge, confidence, and self-perception following each workshop. Significant improvements were found for both participant knowledge and confidence. Participant feedback also indicated a desire for further occupational therapy programming. While further research is needed to fully understand the role of occupational therapy with justice-involved individuals, results indicate the need for occupational therapy services in work release facilities. 2 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS Mental Health Matters Promoting Mental and Emotional Well-being for Justice-Involved Individuals Public Advocates in Community re-Entry (PACE) is a non-profit organization that provides a variety of services to clients with a history of at least one felony conviction or five misdemeanor charges. Their vision as an organization is focused on making the transition from incarceration to the community as smooth as possible by ensuring that clients have access to the necessary resources, which in turn enhances community stability. They aim to help clients gain access to basic necessities, as well as aid them in developing the skills needed to obtain employment and additional services, an important trait for community organizations (Kern et al., 2020). PACEs re-entry coaching services include employment coaching, financial coaching, mental health coaching, and peer recovery coaching for individuals seeking or in recovery from substance use disorders (PACE, n.d.). In addition to these services, PACE partners with Duvall Residential Center to provide life skills training and employment programming to men currently serving work release sentences. This project consisted of the development and implementation of occupational therapy (OT) based mental health and emotional regulation programming from a trauma-informed care perspective for Duvall Residential Center residents. The three weekly workshop sessions supplemented pre-existing programming created by an occupational therapist at PACE that had yet to be implemented at Duvall Residential Center. Mental health programming had been identified as a crucial part in working to reduce recidivism rates and provided clients with strategies and skills to help prepare them to re-enter the community successfully. Data was collected through the utilization of pre- and post-surveys that gathered both quantitative and qualitative data across a total of five workshops. 3 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS Background Shared traits between clients both at PACE and at Duvall Residential Center included a prior history of at least one felony conviction or five misdemeanors and time spent incarcerated, whether that be prior incarceration for PACE clients or current incarceration for Duvall clients. Another trait shared by both groups were the barriers clients faced to successful reintegration into the community. Some barriers commonly identified by clients include lack of reliable transportation, lack of employment, having multiple felonies, not having a valid drivers license, mental health and substance use disorders, and more. According to PACEs 2021 Annual Report, 86% of their clients at intake have an annual income of less than $10,000, and one third of the clients come to PACE without a high school diploma (Public Advocatess in Community Reentry, 2021). While Duvall Residential Center does not report on these statistics, the information gathered from intake forms completed as part of the PACE Advancing Your Career (AYC) Job Readiness workshop at Duvall provided similar data to that of PACEs annual report. In the needs assessment interview, PACEs occupational therapist mentioned that one of the most significant needs noted by Duvall Residential Center was the need to reduce recidivism rates (personal communication, March 4, 2022) and to address mental health from a traumainformed care perspective. The only programming offered by PACE at Duvall Residential Center was the AYC Job Readiness workshop, and while that helped with job obtainment, it did not inherently address mental health, coping skills, and emotional regulation skills needed to maintain employment and reduce recidivism. This project, focused on the development of programming that provides mental health resources from a trauma-informed, OT perspective, was developed from this conversation. The importance of programming like this can be found within the literature on OT with justice-involved individuals. In a study by Muoz et al., (2016), 4 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS they noted that a majority of justice-based OT programming is focused on interpersonal communication, problem-solving, stress management, and coping skills, which are all important aspects of mental health intervention. Mindfulness-based mental health interventions have also been found to have a positive impact in addressing mental illness with justice-involved individuals (Han, 2022). For justice involved-individuals who experienced mental illness, mental health and trauma-informed interventions are crucial to dealing with the internalized stigma surrounding mental health, especially with men (Tomar et al., 2020). Occupational therapists are well equipped to take a trauma-informed approach when working with clients, as establishing rapport and gathering information for an occupational profile are essential to building trust and working to empower clients (Fette et al., 2019). Occupational therapists are also well equipped to help clients identify barriers as well as to create and commit to goals moving forward as part of effective treatment planning and client-centered care (Levenson & Willis, 2019). If traumainformed approaches are not used in interventions with this incarcerated population, there is a good chance that they will not be effective interventions (Mueller et al., 2021). According to Crabtree et al. (2016), some of the main fears and concerns brought up by men who have specifically gone through educational programming in prisons included re-entry fears, lack of self-worth, and not knowing how to use new technology that had come out since their sentencing. In this study, the participants found the educational aspect to be beneficial, but did not find it as beneficial as the social connections being made with the researchers and students, as it provided insight into relationships outside of prison culture. Although current literature provided insight into the role of OT with justice-involved individuals, none of the studies reviewed were conducted in a work release facility. Work release 5 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS facilities are complex in that while residents are still incarcerated, they are allowed to leave the facility for work, doctors appointments, school, and if eligible they can leave the facility to visit family on a family pass (Marion County Community Corrections, n.d.). They can earn certain privileges and opportunities not available to other justice-involved individuals who are not incarcerated at a work release facility. With those privileges comes the responsibility to remain in good standing because if they are caught breaking the rules or abusing those privileges, they lose those privileges and are at risk of getting violated and sent back to jail. Even with those privileges, individuals still experience barriers to occupational participation and face occupational deprivation, which impacts their ability to prepare for successful community reentry (Muoz, 2019). While OT has existed within the justice system for over 70 years, the current literature remains limited in scope of practice as the profession has yet to clearly define its role within the justice system to address these barriers to occupational performance (Muoz, 2019). Therefore, more research is needed to create a larger base of knowledge and to advance the work of occupational therapists with all justice-involved populations. This project aimed to help narrow the gap by collecting both qualitative and quantitative data to show the effectiveness of trauma-informed mental health programming within Duvall Residential Center. It provided data for participants insights of their knowledge, confidence, and self-perception pre- and post-workshop. Most importantly, it provided participants with tools and support to help manage their stress and their emotions, which in turn created the potential to help them maintain employment, manage conflict and relationships in a healthy way, and improve their confidence in themselves. It also created the potential to reduce the likelihood of a participant recidivating as they received information and practiced skills that help manage conflict and difficult emotions as they arise instead of impulsively acting on those feelings. 6 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS Using this data, PACE and Duvall Residential Center can further expand upon or continue the current mental health programming to continue to address and improve client outcomes. Theory The main theory guiding the development of Mental Health Matters was the PersonEnvironment-Occupation-Performance (PEOP) model. PEOP is used with groups or populations and investigates how the interaction between person, environment, and occupation impacts occupational performance (Cole & Tufano, 2020), and this project explored OTs role in the justice system, particularly with men in a locked, work-release facility. The PEOP model guided the investigation of the interactions between this group of men, the intrinsic personal factors and extrinsic environmental factors they face, and the occupations they have been able to maintain during incarceration and their time at Duvall, to see how this impacts mental health and occupational performance (See Figure A1). The information gained through the lens of the PEOP model helped determine the direction of the workshops, as the topics depended on the needs of the men in this group. Major barriers to occupational performance identified by PACEs occupational therapist and Duvall residents included mental health and feelings of readiness to return to life outside the justice system after prolonged occupational deprivation. The Cognitive Behavioral frame of reference (FOR) also influenced the development of this project. This FOR looks at the influence of thoughts and emotions on behaviors and addresses psychological barriers to activity engagement (Cole & Tufano, 2020). The cognitive behavioral FOR encourages occupational therapists to help individuals examine their thoughts and emotions regarding themselves and the circumstances that they are in to help find strategies to address maladaptive thoughts and behaviors and the things that are reinforcing them (Cole & Tufano, 2020). This FOR aligns well with both PEOP and the project goal of helping residents 7 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS manage and understand how their thoughts and emotions impact their behaviors and relationships with others prior to reentering the community (See Figure A2). These thought patterns stemmed from their core beliefs about themselves, others, and what they believe the future looks like for them. Project Design & Implementation This project was developed to finish out a pre-existing curriculum developed by PACEs occupational therapist for Duvall Residential Center clients. The occupational therapist developed four workshops, so this project focused on developing an additional three workshops to complete the curriculum. The capstone student formatted workshops similarly to the ones that had already been developed. Each workshop began with participants filling out an anonymous pre-survey that gathered client data focused on their knowledge, self-confidence, and selfperception in relation to each topic. Following this, the clients completed the educational portion of the workshop which consisted of group discussions, worksheets, short lectures, and activities. The most important part of these workshops was that the clients felt safe and comfortable discussing topics and working on strategies to deal with stress and mental health issues in a healthy and positive way. At the end of each workshop clients filled out a post-survey, which included all pre-survey questions with additional questions that gathered client feedback on what they learned, what they liked about the workshop, and what could be improved. The data collected on these surveys was used to assess changes in client knowledge, selfconfidence, and self-perception relative to the workshop topic. Mental health, emotional regulation, and overall well-being were areas that clients commonly struggled with, and the hope was to see an average of a one-point increase on a 5-point Likert scale from pre-survey to postsurvey for each workshop. This was chosen as a simple way to collect anonymous data to show changes in knowledge, self-confidence, and self-perception from beginning to end of the 8 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS workshop session. As part of the post-survey, participants also answered free response questions to provide qualitative responses from participants on their views of the workshop. Program implementation occurred on a weekly basis, with one workshop per week for 5 weeks. These workshops ran on Monday afternoons from 1 p.m.- 3 p.m. One challenge for implementing this programming was navigating lines of communication with both PACE and Duvall personnel. Workshop dates, timing, materials, and staffing all needed to be approved by both PACE and Duvall Residential Center. This took much longer than anticipated and resulted in a delayed start date for programming, which led to the implementation of 5 of the workshops instead of all 7. One success, however, was that each workshop had between 2-4 participants in attendance. The programming concluded by reviewing the topics covered over each individual workshop and answering any final questions participants had on the materials. Project Outcomes The evaluation plan consisted of designing pre- and post-surveys for each individual Ways to Destress Workshop. Each pre- and post-survey evaluated participant knowledge, confidence, and self-image through a series of questions with answer options on a scale, from strongly disagree to strongly agree (See Appendices B F for complete surveys). The postsurvey also asked whether or not the participant would come to another Ways to Destress Workshop and if they would recommend the course to a friend. In terms of qualitative data, participants were asked what they learned, what they liked about the workshop, what could be improved with the workshop, and other topics they would be interested in seeing. They were also given space for any additional comments they had. Data was collected in this manner to have both numerical data and participant quotes that showed the impact of the workshops. Survey questions were similar across workshops as they all discussed the variables knowledge, confidence, and self-image, but they were worded to be appropriate to each individual workshop. 9 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS This was done to increase the user friendliness of the surveys because although four participants completed multiple workshops, the other four participants only attended one session. Data was not compared between workshops due to the slightly different wording. It was only compared in each individual workshop as well as from pre-survey to post-survey, by variable, across all workshops. The goal was to see a 1-point increase on a 5-point scale for the measured variables of knowledge, confidence, and self-perception. The only workshop that individually achieved this was the emotional regulation workshop, as all areas saw a 1 point or greater average increase from pre-survey to post-survey. Combined data across all workshops showed a 1.40-point average increase for knowledge, a 1.14-point average increase for confidence, and a 0.31-point average increase for self-perception, which indicated that two of the three variables exceeded the goal of seeing a 1-point increase from pre-survey to post-survey. For the variable that did not meet this goal, it is noted that a 1-point increase was not possible due to having a pre-survey average score of 4.38 with a maximum score of 5. Qualitative data analysis revealed overall positive feedback for all workshop areas. Open coding of the data revealed many unusable responses due to being vague in nature or unrelated/irrelevant to the workshop topic. Of the responses that were appropriate to use, themes included that the workshops were helpful and informative (I liked learning the techniques and how interactive the teacher was), appreciation for the time taken to run the workshops (Keep up the good work, yall really got a good influence on people and what they are going through), the desire for additional workshops (You should continue the workshops and keep finding ways to engage others guys in it), and how the workshops served as preventative measures to 10 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS violation and absconding from Duvall Residential Center (I probably wouldve ran if I didnt go to these classes). Summary PACE was created to serve individuals with justice-involvement and to aide in the transition from incarceration back to the community or prepare them for this transition in the future in the case of Duvall residents. While a variety of services are provided to clients both PACE and Duvall, the role of OT and mental health programming is limited. Similarly, literature on the role of OT and mental health programming with justice-involved individuals is also limited. The available literature is focused primarily on communication skills, problem solving, stress management, coping skills, and goal setting (Muoz et al., 2016), with all interventions related to mental health and within the OT scope of practice (American Occupational Therapy Association, 2017). Previous literature guided new program development, with a focus specifically on various ways to manage stress with individuals at an all-male work release facility. Data collected through pre- and post-surveys included both quantitative and qualitative measures, with a focus on participant knowledge, attitudes, and self-perception relative to each workshop. When data was examined across all workshops, participant knowledge was found to have increased on average by 1.4 points on a 5-point Likert scale, while participant confidence increased on average by 1.14 points. Participant self-confidence was found to have increased by 0.31 points on the same Likert scale. Participant qualitative feedback remained positive across all workshops, and emphasized points included the desire for additional workshops and information, as well as participant gratitude for providing stress management strategies and support to participants in this environment. 11 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS Conclusion This project illustrated the importance of expanding the role of OT with justice-involved populations. It clearly demonstrated the positive impact that OT-based mental health services can have on residents in a work release facility to address overall health and well-being, which in turn promotes occupational engagement and occupational justice. Moving forward, PACE now has the tools to further implement these workshops as staffing allows and can utilize the additional mental health resources collected to provide high quality services to clients at Duvall Residential Center. These resources will aid PACEs continued efforts to prepare and assist clients with re-entry into the community and to ultimately work to reduce recidivism rates. With limited OT on site, all materials have been developed in a way that non-OT personnel could implement these workshops and utilize the resources gathered as well, while still making OTs influence clear. Occupational therapy must, as a profession, continue to push for expanding its role in community-based settings, especially those that include justice-involved individuals. While OT in the justice system has existed for decades, more research is needed to fully support OTs role with justice-involved individuals (Schindler, 2019). Additionally, while research exists on the role of OT with re-entry programming within jails (Jaegers et al., 2020), community-based programming (Eberth et al., 2022), and prisons (Visher et al., 2017), there is little to no research available on these programs with individuals in work release facilities specifically. It is crucial for the future of the profession to continue to expand the areas and populations we serve, including work done in justice-based settings. 12 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS References American Occupational Therapy Association. (2017). Mental health promotion, prevention, and intervention in occupational therapy practice. The American Journal of Occupational Therapy, 71(2), 7112410035p1-7112410035p19. https://doi.org/10.5014/ajot.2017.716s03 Cole, M. & Tufano, R. (2020). Applied theories in occupational therapy: A practical approach (2nd Ed.). SLACK Incorporated. Crabtree, J. L., Ohm, D., Wall, J. M., & Ray, J. (2016). Evaluation of a prison occupational therapy informational education program: A pilot study. Occupational Therapy International, 23(4), 401-411. https://doi.org/10.1002/oti.1442 Eberth, S. D., Diaconu, M., & Koob, C. (2022). A cautionary tale of a prisoner re-entry initiative: Lessons learned. The International Journal of Interdisciplinary Social and Community Studies, 17(2), 167-177. https://doi.org/10.18848/2324-7576/cgp/v17i02/167-177 Fette, C., Lambdin-Pattavina, C., & Weaver, L. L. (2019). Understanding and applying trauma-informed approaches across occupational therapy settings [Continuing education article]. OT Practice, 24(5), 35. Han, A. (2022). Effects of mindfulnessbased interventions on psychological distress and mindfulness in incarcerated populations: A systematic review and metaanalysis. Criminal Behaviour and Mental Health. https://doi.org/10.1002/cbm.2230 Jaegers, L. A., Skinner, E., Conners, B., Hayes, C., West-Bruce, S., Vaughn, M. G., Smith, D. L., & Barney, K. F. (2020). Evaluation of the jail-based occupational therapy transition and integration services program for community reentry. The American Journal of 13 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS Occupational Therapy, 74(3), 7403205030p1 7403205030p11. https://doi.org/10.5014/ajot.2020.035287 Kern, S. B., Reitz, S. M., Seruya, F. M., Silveira, J., Smith, B. C., Thompson, T., Kilkuskie, K., Santos, G., & Nguye, A. (2020). Promoting occupational participation in marginalized populations. In M. E. Scaffa & S. M. Reitz (Eds.), Occupational therapy in community and population health practice (3rd ed., pp. 457-487). F.A. Davis. Levenson, J. S., & Willis, G. M. (2019). Implementing trauma-informed care in correctional treatment and supervision. Journal of Aggression, Maltreatment & Trauma, 28(4), 481501. https://doi.org/10.1080/10926771.2018.1531959 Marion County Community Corrections. (n.d.). Community corrections residential facilities. Indy.gov. https://www.indy.gov/activity/community-corrections-residential-facilities Mueller, S., Hart, M., & Carr, C. (2021). Resilience building programs in U.S. corrections facilities: An evaluation of trauma-informed practices in place. Journal of Aggression, Maltreatment & Trauma, 1-20. https://doi.org/10.1080/10926771.2021.2008082 Muoz, J. P. (2019). Mental health practice in criminal justice systems. In C. Brown, V. C. Stoffel, & J. P. Muoz (Eds.), Occupational therapy in mental health: A vision for participation (2nd ed., pp. 615-641). F. A. Davis Company. Muoz, J. P., Moreton, E. M., & Sitterly, A. M. (2016). The scope of practice of occupational therapy in U.S. criminal justice settings. Occupational Therapy International, 23(3), 241254. https://doi.org/10.1002/oti.1427 Public Advocates in Community re-Entry. (n.d.). Our programs and services. https://www.paceindy.org/our-programs-and-services/ Public Advocates in Community re-Entry. (2021). Annual report. PACE. 14 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS https://www.paceindy.org/wp-content/uploads/2022/04/2021-Annual-Report-FINAL.pdf Schindler, V. P. (2019). Introduction to the issue on OT and the criminal justice system. Occupational Therapy in Mental Health, 35(3), 217218. https://doi.org/10.1080/0164212x.2019.1644719 Tomar, N., Brinkley-Rubinstein, L., Ghezzi, M. A., Van Deinse, T. B., Burgin, S., & Cuddeback, G. S. (2019). Internalized stigma and its correlates among justice-involved individuals with mental illness. International Journal of Mental Health, 49(2), 201211. https://doi.org/10.1080/00207411.2019.1703358 Visher, C. A., Lattimore, P. K., Barrick, K., & Tueller, S. (2016). Evaluating the long-term effects of prisoner reentry services on recidivism: What types of services matter? Justice Quarterly, 34(1), 136-165. https://doi.org/10.1080/07418825.2015.1115539 15 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS 16 Appendix A Theory Diagrams Figure 1A OT Theory Model Support from friends and family or lack thereof Stress and inactivity Difficulties with reasoning and thought/emotional processing Developing skills to prepare for community re-entry Life post-incarceration Prison culture Impact of sensory deprivation in prisons Low self-esteem, mental health issues Difficulty with housing and employment services due to felony conviction(s). Locked facility, Public bus transportation, libraries, parks Large urban city, Midwest Impacted by prolonged occupational deprivation Note. This model shows how the Person-Environment-Occupation-Performance (PEOP) model can be applied to the residents at Duvall Residential Center. The occupation being analyzed is skill development to prepare for community re-entry, as noted in the top circle. General intrinsic and extrinsic person and environment factors are listed in each respective circle to indicate their place within the model. Barriers to occupational performance and participation are listed within the performance circle. MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS 17 Figure 2A OT FOR Model Worst case: recidivating Best case: successful skill development for community re-entry Do you view yourself positively or negatively? Do you have the belief others want to help you succeed? Fear, anxiety, excitement, hope What do you see for yourself in the future? Am I ready and prepared to leave the justice system? What will I do once Im released? Note. This model demonstrates the cognitive behavioral frame of reference. It illustrates the relationship between an individuals thoughts, feelings, and behaviors and how they impact one another. It also shows how an individuals core beliefs about themselves, others, and the future impact their thoughts, feelings, and behaviors as well. MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS Appendix B Stress Exploration Surveys Participants filled out a survey before and after completing the workshop. Questions 1-7 were on both the pre- and post-surveys, while questions 8-14 were only included in the post-survey. The surveys began with the following message: Thank you for coming to the Stress Exploration Workshop! Please answer each question honestly. This is NOT a test, there are NO wrong answers! 1.) I know what things, big and small, make my stress levels go up. ( ) Strongly Disagree ( ) Slightly Disagree ( ) Neutral ( ) Slightly Agree ( ) Strongly Agree 2.) I know the difference between positive and negative coping skills for dealing with stress. ( ) Strongly Disagree ( ) Slightly Disagree ( ) Neutral ( ) Slightly Agree ( ) Strongly Agree 3.) I know and can name three positive coping strategies for managing stress. ( ) Strongly Disagree ( ) Slightly Disagree ( ) Neutral ( ) Slightly Agree ( ) Strongly Agree 4.) List three positive coping skills here: 18 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS 5.) I am confident that I can identify the things, big and small, that make my stress levels go up. ( ) Strongly Disagree ( ) Slightly Disagree ( ) Neutral ( ) Slightly Agree ( ) Strongly Agree 6.) I am confident that I can use positive coping strategies to manage my stress ( ) Strongly Disagree ( ) Slightly Disagree ( ) Neutral ( ) Slightly Agree ( ) Strongly Agree 7.) My ability to manage my stress levels makes me feel good about myself. ( ) Strongly Disagree ( ) Slightly Disagree ( ) Neutral ( ) Slightly Agree ( ) Strongly Agree 8.) What did you learn from this workshop? 9.) What did you like about this workshop? 10.) What could be changed or improved with this workshop? 19 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS 11.) Would you come to another Ways to Destress workshop after taking this one? ( ) Yes ( ) No ( ) Maybe ( ) Other: _____________________________ 12.) Would you recommend this course to a friend? ( ) Yes ( ) No ( ) Maybe ( ) Other: _____________________________ 13.) Is there a topic for a workshop you would like to see in the future? 14.) Any other comments? 20 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS Appendix C Relaxation/Meditation Surveys Participants filled out a survey before and after completing the workshop. Questions 1-7 were on both the pre- and post-surveys, while questions 8-14 were only included in the post-survey. The surveys began with the following message: Thank you for coming to the Relaxation/Meditation Workshop! Please answer each question honestly. This is NOT a test, there are NO wrong answers! 1.) I know what relation strategies and meditation are. ( ) Strongly Disagree ( ) Slightly Disagree ( ) Neutral ( ) Slightly Agree ( ) Strongly Agree 2.) I know how to use relaxation strategies and mediation to manage my stress. ( ) Strongly Disagree ( ) Slightly Disagree ( ) Neutral ( ) Slightly Agree ( ) Strongly Agree 3.) I know and can name three relaxation strategies for managing stress. ( ) Strongly Disagree ( ) Slightly Disagree ( ) Neutral ( ) Slightly Agree ( ) Strongly Agree 4.) List three positive coping skills here: 21 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS 5.) I am confident that I can identify how relaxation strategies and meditation can help manage my stress. ( ) Strongly Disagree ( ) Slightly Disagree ( ) Neutral ( ) Slightly Agree ( ) Strongly Agree 6.) I am confident that I can use relaxation strategies and meditation to manage my stress. ( ) Strongly Disagree ( ) Slightly Disagree ( ) Neutral ( ) Slightly Agree ( ) Strongly Agree 7.) Using relaxation strategies and meditation makes me feel good about myself. ( ) Strongly Disagree ( ) Slightly Disagree ( ) Neutral ( ) Slightly Agree ( ) Strongly Agree 8.) What did you learn from this workshop? 9.) What did you like about this workshop? 10.) What could be changed or improved with this workshop? 22 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS 11.) Would you come to another Ways to Destress workshop after taking this one? ( ) Yes ( ) No ( ) Maybe ( ) Other: _____________________________ 12.) Would you recommend this course to a friend? ( ) Yes ( ) No ( ) Maybe ( ) Other: _____________________________ 13.) Is there a topic for a workshop you would like to see in the future? 14.) Any other comments? 23 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS Appendix D Goal Setting Surveys Participants filled out a survey before and after completing the workshop. Questions 1-6 were on both the pre- and post-surveys, while questions 7-13 were only included in the post-survey. The surveys began with the following message: Thank you for coming to the Goal Setting Workshop! Please answer each question honestly. This is NOT a test, there are NO wrong answers! 1.) I know how to set goals for myself. ( ) Strongly Disagree ( ) Slightly Disagree ( ) Neutral ( ) Slightly Agree ( ) Strongly Agree 2.) I know what my goals for the future are. ( ) Strongly Disagree ( ) Slightly Disagree ( ) Neutral ( ) Slightly Agree ( ) Strongly Agree 3.) I know what the 8 dimensions of well-being are and how I can use them to help set goals for myself. ( ) Strongly Disagree ( ) Slightly Disagree ( ) Neutral ( ) Slightly Agree ( ) Strongly Agree 24 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS 4.) I am confident that I set goals for myself for the future. ( ) Strongly Disagree ( ) Slightly Disagree ( ) Neutral ( ) Slightly Agree ( ) Strongly Agree 5.) I am confident that I can use the 8 dimensions of well-being to help set goals for myself. ( ) Strongly Disagree ( ) Slightly Disagree ( ) Neutral ( ) Slightly Agree ( ) Strongly Agree 6.) My ability to set goals for the future makes me feel good about myself. ( ) Strongly Disagree ( ) Slightly Disagree ( ) Neutral ( ) Slightly Agree ( ) Strongly Agree 7.) What did you learn from this workshop? 8.) What did you like about this workshop? 9.) What could be changed or improved with this workshop? 25 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS 10.) Would you come to another Ways to Destress workshop after taking this one? ( ) Yes ( ) No ( ) Maybe ( ) Other: _____________________________ 11.) Would you recommend this course to a friend? ( ) Yes ( ) No ( ) Maybe ( ) Other: _____________________________ 12.) Is there a topic for a workshop you would like to see in the future? 13.) Any other comments? 26 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS Appendix E Emotional Regulation Surveys Participants filled out a survey before and after completing the workshop. Questions 1-8 were on both the pre- and post-surveys, while questions 9-15 were only included in the post-survey. The surveys began with the following message: Thank you for coming to the Emotional Regulation Workshop! Please answer each question honestly. This is NOT a test, there are NO wrong answers! 1.) I know what emotional regulation is. ( ) Strongly Disagree ( ) Slightly Disagree ( ) Neutral ( ) Slightly Agree ( ) Strongly Agree 2.) I know what the four zones of regulation are. ( ) Strongly Disagree ( ) Slightly Disagree ( ) Neutral ( ) Slightly Agree ( ) Strongly Agree 3.) List the four zones of regulation here: 4.) I know what emotions go into each zone. ( ) Strongly Disagree ( ) Slightly Disagree ( ) Neutral ( ) Slightly Agree ( ) Strongly Agree 27 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS 5.) I know strategies I can use when I am in each zone to help make myself feel better. ( ) Strongly Disagree ( ) Slightly Disagree ( ) Neutral ( ) Slightly Agree ( ) Strongly Agree 6.) I am confident that I can identify what emotions go in each zone. ( ) Strongly Disagree ( ) Slightly Disagree ( ) Neutral ( ) Slightly Agree ( ) Strongly Agree 7.) I am confident that I can use strategies when I am in each zone to make myself feel better. ( ) Strongly Disagree ( ) Slightly Disagree ( ) Neutral ( ) Slightly Agree ( ) Strongly Agree 8.) My ability to regulate my emotions makes me feel good about myself. ( ) Strongly Disagree ( ) Slightly Disagree ( ) Neutral ( ) Slightly Agree ( ) Strongly Agree 9.) What did you learn from this workshop? 28 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS 10.) What did you like about this workshop? 11.) What could be changed or improved with this workshop? 12.) Would you come to another Ways to Destress workshop after taking this one? ( ) Yes ( ) No ( ) Maybe ( ) Other: _____________________________ 13.) Would you recommend this course to a friend? ( ) Yes ( ) No ( ) Maybe ( ) Other: _____________________________ 14.) Is there a topic for a workshop you would like to see in the future? 15.) Any other comments? 29 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS Appendix F Journaling Surveys Participants filled out a survey before and after completing the workshop. Questions 1-4 were on both the pre- and post-surveys, while questions 5-11 were only included in the post-survey. The surveys began with the following message: Thank you for coming to the Journaling Workshop! Please answer each question honestly. This is NOT a test, there are NO wrong answers! 1.) I know what the different types of journaling are. ( ) Strongly Disagree ( ) Slightly Disagree ( ) Neutral ( ) Slightly Agree ( ) Strongly Agree 2.) I know how journaling can help manage stress. ( ) Strongly Disagree ( ) Slightly Disagree ( ) Neutral ( ) Slightly Agree ( ) Strongly Agree 3.) I am confident that I can journal to manage my stress. ( ) Strongly Disagree ( ) Slightly Disagree ( ) Neutral ( ) Slightly Agree ( ) Strongly Agree 30 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS 4.) Journaling makes me feel good about myself. ( ) Strongly Disagree ( ) Slightly Disagree ( ) Neutral ( ) Slightly Agree ( ) Strongly Agree 5.) What did you learn from this workshop? 6.) What did you like about this workshop? 7.) What could be changed or improved with this workshop? 8.) Would you come to another Ways to Destress workshop after taking this one? ( ) Yes ( ) No ( ) Maybe ( ) Other: _____________________________ 9.) Would you recommend this course to a friend? ( ) Yes ( ) No ( ) Maybe ( ) Other: _____________________________ 31 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS 10.) Is there a topic for a workshop you would like to see in the future? 11.) Any other comments? 32 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS 33 Appendix G Doctoral Capstone Experience and Project Weekly Planning Guide Week DCE Stage (orientation, screening/evaluation, implementation, discontinuation, dissemination) 1 Orientation Screening/Evaluation 2 Orientation Screening/Evaluation Weekly Goal 1.) Complete PACE orientation by the end of the week 2.) Attend virtual Duvall orientation and complete all paperwork by the end of the week Objectives Meet virtually with site mentor, in-person with other site personnel, complete orientation to the site and introduce myself and my role for the next 14 weeks Understand work environment, where else I might fit in besides my project within the organization 1.) Complete inEstablish what person orientation programming needs at Duvall are at Duvall, what 2.) Finalize MOU, programming exists resign, and turn already in Tasks Work on updating/editing literature and MOU Date complete 1/9/23 1/13/23 Create tracking sheet for hours and what I do every day whether I am on or off site Ensure all paperwork for Duvall is done Finalize and turn in MOU Create a list of program ideas for Duvall Observe in Duvall 1/16/23 1/20/23 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS 34 Understand culture of Duvall, dress code, etc 3 4 Screening/Evaluation Screening/Evaluation 1.) Update pre/post survey and pre/post test for AYC workshop 2.) Finalize topics for mental health programming at Duvall 1.) Pilot new pre/post survey for AYC job readiness course 2.) Finalize programming for mental health workshops 3.) Check in on Advocacy Day Progress Observe at Duvall Choose 3 topics to create programming for in addition to the 4 programs already created Continue to establish role at both PACE and Duvall Confirm all clear to begin mental health workshops starting next week Determine next steps in Advocacy Day planning with upper management Meet with site mentor in person to review informal needs assessment results and discuss programming at Duvall Continue to work on program development 1/23/231/27/23 Find/create resources for mental health workshops Update pre/post survey for AYC workshop Update pre/post-test for AYC workshop Finish planning mental health group workshops Gather all materials for workshops Follow up on HB 1005 progress Make flyer and sign up sheet for mental health workshop to start next week Meet with employment team 1/30/232/3/23 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS 5 Screening/Evaluation (stuck in waiting) 1.) Clarify timeline for program implementation 2.) Determine roles for Duvall transition period 35 Clear up confusion surrounding program implementation Clarify transition timeline as one staff member leaves and another transitions into the AYC role Determine if any changes will occur in my role at Duvall 6 Screening/Evaluation (stuck in waiting) 1.) Revise program implementation plan 2.) Establish clear roles and expectations for duration of capstone project Shift implementation plan so it consists of only five workshops instead of seven Clarify roles and expectations to reduce miscommunication rates and reduce stress to clarify AYC pre/post-test issues Update flyer and workshop materials to reflect new timeline Continue to assist with Duvall AYC course (making emails, resumes, etc) 2/6/232/9/23 Upload finalized workshop materials into SharePoint Meet with ED and Manager of Employment services to clarify transition timeline and roles Meet with DCE Coordinator to establish new implementation plan Discuss with site mentor issues encountered this week to create a plan moving forward Meet with Faculty Advisor to discuss plan to best manage stress/events of the week and time on-site moving forward Meet with Executive Director to debrief events of 2/13/232/17/23 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS 7 Implementation 1.) Finally begin programming, implement session 1/5 2.) Attend and table at IOTA Capitol Day 36 Collect pre/post data for session 1 Demonstrate knowledge of OT in the justice system the week and to clarify my role, generate clear expectations, and confirm program implementation can begin next week Run first programming session 2/20/232/24/23 Finalize materials and poster for IOTA Capitol Day Present poster at IOTA Capitol Day Make minor adjustments to future programming materials 8 9 Implementation Implementation 1.) Implement session 2/5 2.) Begin to draft PACE Advocacy Day materials 3.) Organize Duvall files from previous staff members desk 1.) Implement session 3/5 Collect pre/post data for session 2 Run second programming session Determine what files from old folders can be discarded and which need to be saved Discard old files that are not needed, reorganize other folders that were found Determine formatting for Advocacy Day materials Collect pre/post data for session 3 2/27/233/3/23 Begin to draft Advocacy Day materials on Canva and Google Docs Return to assisting with AYC at Duvall Run third programming session 3/6/233/10/23 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS 37 2.) Continue to work Research the status of on Advocacy Day bills PACE is materials following for Advocacy Day 10 11 12 Implementation Implementation/Discontinue Analyze 1.) Implement session 4/5 2.) Assist with preparation and running of Family Fun Night Event 3.) Finalize Advocacy Day materials 1.) Implement session 5/5 2.) Attend Advocacy Day 3.) Train new staff member on Duvall admin responsibilities 1.) Work on data analysis and Send out first draft of Advocacy Day materials to be edited Collect pre/post data for session 4 Gather and prepare food/materials for Family Fun Night Prepare for upcoming transition out of Duvall Collect pre/post data for session 5 Participate in Advocacy Day at the State House Show new staff member how to complete weekly Duvall admin tasks Input quantitative and qualitative data into Continue to assist with AYC at Duvall Send ED first draft of Advocacy Day materials for feedback Run fourth programming session 3/13/233/17/23 Go on material/food run for event with case manager Assist staff in set up and running of Family Fun Night event Continue to assist with AYC at Duvall Run fifth and final programming session 3/20/233/24/23 Sit in on bill hearings at Advocacy Day Teach Duvall admin staff member how to input pre/post surveys, make the folders, create client resumes and emails, etc. Create graphs with quantitative data, > 1 point 3/27/233/31/23 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS dissemination presentation 2.) Continue to transfer out of Duvall role and train new staff member 13 14 Analyze/Disseminate Wrap Up 38 spreadsheets Check in with new staff member to answer questions Create Google Slides presentation for dissemination 1.) Finish data analysis 2.) Disseminate to Executive Director and Manager of Employment Services Finalize and practice dissemination presentation 1.) Conduct all final meetings with various 2.) Transition fully out of role at PACE/Duvall Finalize mental health binder and resources Complete final meeting with site mentor Determine if any additional dissemination to Duvall is necessary at this time increase for 2/3 question areas Organize/determine appropriate groupings for qualitative responses, feedback was positive Resend materials to new staff member to ensure access to all necessary resources moving forward Organize presentation slides Present dissemination presentation for PACE 4/3/234/7/23 Hold off on disseminating/presenting to Duvall per executive director Assist with various needs at PACE/Duvall as needed as capstone comes to an end Say goodbye to clients at Duvall Print out last of mental health resources for binder 4/10/234/14/23 MENTAL HEALTH & JUSTICE-INVOLVED INDIVIDUALS 39 Complete last days at PACE and Duvall Virtual meeting with site mentor, complete site eval prior to meeting Turn in badge on last day  ...

... MENTAL HEALTH AND CARE FOR VETERANS FROM HOMELESSNESS Addressing Mental Health and Access to Care in Veterans Transitioning from Homelessness Ally Reckers May 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Dr. Christine Kroll OTD, MS, OTR, FAOTA Dr. Alissia Garabrant, OTD, MS, OTR 1 MENTAL HEALTH AND CARE FOR VETERANS FROM HOMELESSNESS 2 Abstract Veterans who experience homelessness are at high risk for physical and mental health challenges. Difficulties with mental health and access to proper medical treatment was a gap found in care for veterans transitioning from homelessness. Therefore, this DCE worked to assess mental health and access to care in veterans transitioning from homelessness. The project aspect focused on the pre/post results of two veteran participants in an individualized mental health intervention program consisting of three sessions over eight weeks. Pre/Post test data showed improvements in both veteran participants in different areas, including mental and physical well-being, healthy leisure/quiet recreation participation, and satisfaction with completion of daily ADLs/IADLs. The experience aspect focused on observing the interdisciplinary workings of the care team for these veterans and creating a new standardized referral system to OT services. The standardized referral system allows prioritization of care and increased preparation prior to OT evaluation. MENTAL HEALTH AND CARE FOR VETERANS FROM HOMELESSNESS 3 Addressing Mental Health and Access to Care in Veterans Transitioning from Homelessness This doctoral capstone experience (DCE) took place at the Cincinnati Veteran Affairs (VA) in the Community Outreach Division (COD). Within COD, I worked specifically with veterans who are a part of the U.S. Department of Housing and Urban Development-VA Supportive Housing (HUD-VASH) program. As stated by the VA, HUD-VASH is a collaborative program which pairs HUDs Housing Choice Voucher (HCV) rental assistance with VA case management and supportive services for homeless Veterans (U.S. Department of Veterans Affairs, 2022). Through this program, supportive services are provided to help veterans maintain housing in the community. I worked in tandem with the Cincinnati VA COD and HUD-VASH program to help veterans who have experienced recent homelessness to sustain housing and thrive in their new home environments. Experts found that, the experience of homelessness itself exacerbates the myriad mental and physical health challenges Veterans experience (Crone, et al., 2022, p.2). Therefore, I explored how the implementation of individualized mental health interventions can improve well-being, lead to sustainment of housing, and enhance participation in a safe and healthy lifestyle for this veteran population. I also evaluated and modified the current referral process of veterans in the HUD-VASH program to receive occupational therapy (OT) services. This was vital to make sure that care is prioritized and all veterans that need OT services receive them. This scholarly report will aim to inform you on the efforts of this DCE to improve mental health and access to care for veterans in the HUD-VASH program. It will provide useful information on the background of the site and population, the guiding theories for the DCE, project design and implementation, and the outcomes of the project. MENTAL HEALTH AND CARE FOR VETERANS FROM HOMELESSNESS 4 Background Veterans are a high-risk population for multiple health and safety challenges following their time in the service (Nichter et al., 2022). Scholars state, Estimates suggest veterans are approximately 150% more likely to die by suicide, over 50% more likely to experience homelessness, and 6.5% more likely to experience incarceration in comparison to their nonveteran peers (Fargo et al., 2012; Office of Mental Health & Suicide Prevention, 2019; Ross, Waterhouse-Bradley, Contractor, & Armour, 2018, as cited in Edwards, et al., 2021, p.621). Homelessness is also an issue that has distressing effects on individuals, both physically and psychologically, and can intensify previously existing health issues and challenges (Crone, et al., 2022). The trauma that an individual may experience from homelessness can affect multiple areas of life and well-being. Given that there is high risk for health and safety challenges for both veterans and individuals who experience homelessness, veterans that experience homelessness after their time in service are at higher risk for negative health experiences and the need for care. Access to and engagement with care can be difficult for homeless or previously homeless veterans. Barriers to care include, but are not limited to, lack of reliable transportation, competing economic and medical needs, and distrust of the medical system (Crone et al., 2022 p.2). Due to these barriers related to homelessness, many veterans do not seek out or receive the care they need, specifically when it comes to mental health (Kaplan et al., 2019). Difficulty with accessing services leads to worsening health problems, the presence of co-occurring conditions, and can be a predictor of suicidal thoughts and/or attempts (Tsai et al., 2016, as cited in Holliday, et al., 2022). Some of the common co-occurring conditions that these veterans may experience are mental illness and substance use disorder (Ding et al., 2018, Finlay et al., 2021, as cited in Garvin, et al., 2022). Veterans who experience homelessness can often experience co-occurring MENTAL HEALTH AND CARE FOR VETERANS FROM HOMELESSNESS 5 conditions, disorders, and challenges due to a variety of reasons. Co-occurring conditions, physically or mentally, could have pre-existed from the veterans time in service or other contexts of life, but can be exacerbated by effects of homelessness. When performing a needs assessment with the OT for HUD-VASH, a common theme mentioned was mental health. One thing that was discussed specifically with this population is the need for exploration of treatment ideas for mental health and addressing anxiety, depression, and PTSD in group and/or individual settings (C. Liber, personal communication, November 10, 2022). These are areas that show a gap in care. Along with this, not every veteran in HUDVASH is referred to or in need of OT services. Due to OT being a newer role in this area, the referral process is on a need-to-need basis and is put in to the documentation system by the social workers and nurses. Therefore, the OT for HUD-VASH mentioned the need for a way to standardize referrals through a screening and triage process. This will allow all veterans who need OT services to receive them (C. Liber, personal communication, November 10, 2022). Much of the current literature focuses on mental health in veterans or mental health in the homeless population, but there is a gap when it comes to veterans who have experienced homelessness and how their mental health needs can be met. The purpose of this DCE was to enhance mental health integration into routine treatment and improve access to care for veterans transitioning from homelessness. These two areas are gaps in care that were found both in the literature and through the needs assessment completed with the Cincinnati VA HUD-VASH occupational therapist. Theoretical Framework The occupation-based model that guided this DCE was the Canadian Model of Occupational Performance and Engagement (CMOP-E). The CMOP-E focuses on an individuals spirituality, MENTAL HEALTH AND CARE FOR VETERANS FROM HOMELESSNESS 6 which consists of the will, sense of self-determination, meaning, and purpose of the person and how the components of person, occupation, and environment affects and is affected by a persons spirituality (Cole & Tufano, 2020). Through this DCE, I worked to discover the spirituality of the veterans I worked with and provided mental health programming that aligned with what is meaningful to them to positively influence their safety, independence, and well-being in their daily lives. Additional models that guided this DCE are the Transtheoretical Model of Change and the VAs Whole Health Model. The transtheoretical model of change allowed me to look specifically at the causes and triggers of homelessness and challenges with mental health and how it leads to a decrease in wellness. My goal was to help improve areas of health and wellness, with an emphasis on mental health, to enhance occupational performance and help the veterans begin moving through the 6-step cycle of change (LaMorte, 2022). While I recognized that I may not have been able to help veterans complete the full cycle of change in my 14 weeks with them, I hoped to initiate action by helping them notice the need for change and provide an avenue to create healthy goals and a plan to meet these goals. The VAs Whole Health model was used as a guide to holistic treatment which aligning specifically with the VAs values and initiatives. Whole Health looks at the person in the center and the eight aspects of the Circle of Health surrounding the person. The components of the Circle of Health include working your body, surroundings, personal development, food and drink, recharge, family/friends/coworkers, spirit and soul, and power of the mind (Malecki et al., 2020, p. 656). These areas were a good guide for assessment and creating healthy goals. Research shows that improvement in multiple areas of health was achieved when goals were centered around the eight Circle of health self-care areas (U.S. Department of Veterans Affairs Office of Patient Centered Care and Cultural MENTAL HEALTH AND CARE FOR VETERANS FROM HOMELESSNESS 7 Transformation, 2021). This Whole Health system of care model and Circle of Health was an important guide when planning my DCE to ensure patient-centered care for veterans to best meet their goals. Project Design and Implementation The primary focus when working with the veteran population that is transitioning out of homelessness is usually on finding and providing housing. The support needed to thrive after being housed can be neglected at times. This support is important for participation in healthy occupation, social participation, and community engagement for life satisfaction and sustainment of housing (OConnell, Tsai, & Rosenheck, 2022). Therefore, when designing this DCE, I chose to focus on supporting mental health, quality of life improvement, and access to care within this population. For evaluation purposes, the participants completed the Canadian Occupational Performance Measure (COPM) and part of the VAs Personal Health Inventory (PHI) before and after intervention programming. The COPM is an evidence-based outcome measure that was completed to identify occupational performance problems, concern, and issues for the individual. It also measures the needs, expectations, and wants of the individuals daily life and activities (Law, et al., 2014). The PHI is a self-reported measure related to an individuals perceptions on their physical, mental, and emotional well-being and life satisfaction (U.S. Department of Veterans Affairs, 2019). These theoretically based evaluation methods were chosen to look at changes in mental health, well-being, and occupational performance after intervention programming to properly assess outcomes related to the purpose of the DCE. After the evaluation was completed, I worked with my site mentor to schedule the veteran participants and discussed frequency of visits based on their needs. Together, my site MENTAL HEALTH AND CARE FOR VETERANS FROM HOMELESSNESS 8 mentor and I decided on seeing the veterans every other week for about eight weeks resulting in three sessions dedicated to intervention. This left some buffer room for cancellations and reschedules. I then started outlining and creating content for the first individualized sessions with the veteran participants based on their assessment results. The following sessions were planned based on veterans personal goals, prior session feedback and results, and cooperation and participation with interventions. Administration of the COPM and PHI outcome measures were completed before and after the completion of the intervention sessions. Other aspects of my project included the completion of modifications to the referral system to assist with prioritizing and improving access to care for all veterans in HUD-VASH who need OT services. This went from referrals occurring within evaluation and progress notes of team members to a condensed and uniform referral document for the team to fill out and provide directly to the occupational therapist. This form contained more information about the veteran and the challenges observed to allow the occupational therapist to triage the caseload, prioritize veterans based on needs, and prepare for sessions in advance. Lastly, for retention purposes in the realm of mental health treatment, I completed a plethora of research and created an Evidence-Based Mental Health Resource Guide for the HUD-VASH OT and other team member to use and refer to when integrating mental health into treatment. Project Outcomes This section explains the evaluation process and associated outcomes of the DCE. The full evaluation plan is represented in Appendix A. This table shows that participants completed a two-part evaluation, consisting of the COPM and PHI, before and after the intervention period to effectively measure project outcomes. It also shows that an interview-based collection method MENTAL HEALTH AND CARE FOR VETERANS FROM HOMELESSNESS 9 was used to evaluate the change in access to care before and after the installation of the new referral process to OT services. The COPM helped to identify the needs, expectations, and wants of the individuals daily life and activities and the occupational performance problems, concern, and issues that are barriers to meeting these occupational needs. Areas of focus for intervention were chosen for each participant based on their identification of the importance of each area of the COPM. The COPM areas of focus for participant one were household management, quiet recreation, and socialization. The COPM areas of focus for participant two were functional mobility, quiet recreation, and socialization. These areas were used as a guide for planning intervention sessions. The pre-post test COPM results for both veteran participants are represented in Figure B1. These results showed an improvement in total performance and total satisfaction scores for the areas of focus for participant one. Participant two showed a slight decrease in total performance and satisfaction scores for the areas of focus, likely due to poor circumstances of increased pain at the time of post evaluation. Despite this, the participant reported feeling equipped with resources to improve participation in quiet recreation activities and scores were maintained for the focus area of socialization. Maintaining current levels was an important focus with veteran two due to high initial scores on the COPM. The VA PHI helped understand the veterans perceptions on their physical, mental, and emotional well-being and life satisfaction. The pre-post test PHI results for both veteran participants are represented in Figure B2. These results show that participant one improved in their physical well-being and maintained life satisfaction. Participant one decreased in mental/emotional well-being, likely due to circumstances related to grief associated with the time of the year the post-evaluation was administered. Participant two showed an improvement in MENTAL HEALTH AND CARE FOR VETERANS FROM HOMELESSNESS 10 mental/emotional well-being and maintained progress in physical well-being. Patient showed a decrease in overall life satisfaction, but did not expand on reasoning for this change. Evaluation of change in access to care before and after the installation of the new referral process to OT services was completed. This was done through interviewing the OT on the HUDVASH team. Results show that, while the new referral process is still in the process of being adopted into practice, the HUD-VASH OT can already notice a difference in being able to prioritize care and be better prepared for effective treatment (C. Liber, personal communication, November 10, 2022). Summary When performing a needs assessment with the OT from HUD-VASH, a common theme mentioned was mental health. One aspect that was discussed specifically with the population of veterans transitioning from homelessness is the need for mental health treatment ideas addressing anxiety, depression, and PTSD in group and/or individual settings (C. Liber, personal communication, November 10, 2022). Veterans are a high-risk population for many mental and physical health challenges following their time in service and beginning re-entry to the community (Nichter et al., 2022). Homelessness is a social issue that also poses a great amount of risks to an individuals overall health and well-being (Kaplan et al., 2019). Therefore, veterans who experience homelessness are at an even high risk of oncoming health issues and the pronouncement of existing issues, including risks similar to major mental health concerns, such as suicide. Multiple sources cited that, Many of the risk factors for suicidality and homelessness among Veterans overlap, including traumatic brain injury (TBI) history, psychiatric conditions, substance use disorder, low income, low social support, and cognitive dysfunction (Brenner et al., 2017; Crocker et al., 2019; Kang & Bullman, 2008; Lemaire & MENTAL HEALTH AND CARE FOR VETERANS FROM HOMELESSNESS 11 Graham, 2011; Metraux et al., 2013; Office of Suicide Prevention, 2019; Pietrzak et al., 2010; Tanielian & Jaycox, 2008; Tsai & Rosenheck, 2015; Twamley et al., 2019, as cited in Keller, et al., 2022). Therefore, with information found during the needs assessment and literature search, the best direction for an effective project in this setting would be to focus on mental health. Specifically, how individualized and evidence-based mental health intervention incorporated into regular HUD-VASH treatment can affect quality of life and improve outcomes in veterans transitioning from homelessness. Results from the project shows that in just three individualized mental health sessions, veteran participants improved in areas such as mental well-being, healthy leisure/quiet recreation participation, and satisfaction with completion of daily ADLs/IADLs. Veterans maintained original status or showed a decrease in scores likely due to limitations related to life circumstances, length of program, and frequency. Conclusion The major finding of this DCE is the need for increased OT presence and mental health integration in the care provided to veterans transitioning from homelessness. The HUD-VASH team was provided with an evidence-based mental health intervention resource guide to assist with increased integration of mental health intervention into treatment. The guide provided evidence for the benefits of all interventions included and allowed for easy implementation from all disciplines with clearly stated instructions and printable templates and resources. The site was also provided with clear pre/post-test data from individualized mental health intervention programming with veteran participants. This data is useful in the advocacy efforts for increased OT presence in HUD-VASH and was presented to the site in a presentation format. MENTAL HEALTH AND CARE FOR VETERANS FROM HOMELESSNESS 12 Mental health is a continuously emerging discipline within the scope of OT practice. Further research on the benefits of mental health intervention integration into routine care of veterans transitioning from homelessness is important for the continued development of mental health in OT. Completing research of mental health intervention benefits with this population over a longer period of time, increased frequency of treatment, and a larger sample size could give a bigger picture on the many advantages of mental health in OT on quality of life and independence. MENTAL HEALTH AND CARE FOR VETERANS FROM HOMELESSNESS 13 References Cole, M. & Tufano, R. (2020). Applied theories in occupational therapy: A practical approach (2nd Ed.). SLACK Incorporated. Crone, B., Arenson, M., Cortell, R., & Carlin, E. (2022). Comparing Trauma Treatment Outcomes Between Homeless and Housed Veterans in a VA PTSD Clinical Program. Community Mental Health Journal, 111. https://doi.org/10.1007/s10597-022-01061-2. Edwards, E. R., Barnes, S., Govindarajulu, U., Geraci, J., & Tsai, J. (2021). Mental health and substance use patterns associated with lifetime suicide attempt, incarceration, and homelessness: A latent class analysis of a nationally representative sample of U.S. veterans. Psychological Services, 18(4), 619631. https://doi.org/10.1037/ser0000488. Garvin, L. A., Greenan, M. A., Edelman, E. J., Slightam, C., McInnes, D. K., & Zulman, D. M. (2022). Increasing Use of Video Telehealth Among Veterans Experiencing Homelessness with Substance Use Disorder: Design of A Peer-Led Intervention. Journal of Technology in Behavioral Science, 112. https://doi.org/10.1007/s41347-022-00290-2. Holliday, R., Kinney, A. R., Smith, A. A., Forster, J. E., Liu, S., Monteith, L. L., & Brenner, L. A. (2022). A latent class analysis to identify subgroups of VHA using homeless veterans at greater risk for suicide mortality. Journal of Affective Disorders, 315, 162167. https://doi.org/10.1016/j.jad.2022.07.062. Kaplan, L. M., Vella, L., Cabral, E., Tieu, L., Ponath, C., Guzman, D., & Kushel, M. B. (2019). Unmet mental health and substance use treatment needs among older homeless adults: Results from the HOPE HOME Study. Journal of Community Psychology, 47(8), 1893 1908. https://doi.org/10.1002/jcop.22233. MENTAL HEALTH AND CARE FOR VETERANS FROM HOMELESSNESS 14 Keller, A. V., Clark, J. M. R., Muller-Cohn, C. M., Jak, A. J., Depp, C. A., & Twamley, E. W. (2022). Suicidal Ideation in Iraq and Afghanistan Veterans With Mental Health Conditions at Risk for Homelessness. American Journal of Orthopsychiatry, 92(1), 103 108. https://doi.org/10.1037/ort0000590. LaMorte, W. W. (2022, November 3). The Transtheoretical Model (Stages of Change). Behavioral Change Models. Retrieved January 13, 2023, from https://sphweb.bumc.bu.edu/otlt/mphmodules/sb/behavioralchangetheories/behavioralchangetheories6.html. Law, M., Baptiste, S., Carswell, A., McColl, M., Polatajko, H., & Pollock, N. (2014). The Canadian Occupational Performance Measure. 5th ed. Malecki, H. L., Gollie, J. M., & Scholten, J. (2020). Physical Activity, Exercise, Whole Health, and Integrative Health Coaching. Physical medicine and rehabilitation clinics of North America, 31(4), 649663. https://doi.org/10.1016/j.pmr.2020.06.001 Nichter, B., Tsai, J., & Pietrzak, R. (2022). Prevalence, correlates, and mental health burden associated with homelessness in U.S. military veterans. Psychological Medicine, 1-11. doi:10.1017/S0033291722000617. OConnell, M., Tsai, J., & Rosenheck, R. (2022). Beyond Supported Housing: Correlates of Improvements in Quality of Life Among Homeless Adults with Mental Illness. Psychiatric Quarterly, 111. https://doi.org/10.1007/s11126-022-10010-x. U.S. Department of Veterans Affairs. (2019). Whole Health for Life: Personal Health Inventory. https://www.va.gov/wholehealth/docs/10-773_PHI_July2019_508.pdf. MENTAL HEALTH AND CARE FOR VETERANS FROM HOMELESSNESS 15 U.S. Department of Veterans Affairs. (2022, February 10). VA Homeless Programs: U.S. Department of Housing and Urban Development-VA Supportive Housing (HUD-VASH) Program. https://www.va.gov/homeless/hud-vash.asp. U.S. Department of Veterans Affairs: Office of Patient Centered Care and Cultural Transformation (2021). Live Whole Health: Whole Health, It Starts With Me [Infographic]. va.gov/wholehealth. https://www.va.gov/WHOLEHEALTH/docs/LWH-Introduction_508.pdf. MENTAL HEALTH AND CARE FOR VETERANS FROM HOMELESSNESS 16 Appendix A Evaluation Methods Objectives Data to be collected Mental/Emotional well-being in veterans will improve. Participant self-report assessment of individual mental/emotional well-being Occupational function in veterans will increase. Participant self-report assessment of individual occupational functioning Life satisfaction in veterans will improve. Participant self-report assessment of individual life satisfaction Data collection method/instrum ent VA Whole Health Personal Health Inventory Canadian Occupational Performance Measure VA Whole Health Personal Health Inventory and Canadian Occupational Performance Measure Interview/Recall Data analysis Analysis of change in mental/emotional well-being from baseline to postintervention Analysis of change in occupational functioning from baseline to postintervention Analysis of change in life satisfaction from baseline to postintervention Improved access to OT self-report on Analysis of change in care through prioritization/triage of care access to care from increased use of a before and after use of referral baseline to poststandardized sheet improved referral referral sheet process Appendix A. This table describes the objectives in which this DCE aims to meet and how progress will be evaluated. MENTAL HEALTH AND CARE FOR VETERANS FROM HOMELESSNESS 17 Appendix B Pre/Post Outcomes COPM Scores 8 6 4 Pre Test Scores 2 Post Test Scores 0 Participant 1 Total Performance Scores Participant 2 Total Performance Scores Participant 1 Total Satisfaction Scores Participant 2 Total Satisfaction Scores Figure B1. This figure is separated by participant, domain, and pre-post test scores. A higher score indicates higher perceived levels of participant performance and satisfaction. 6 5 Pre Test Scores Post Test Scores Personal Health Inventory Scores 4 3 2 1 0 Participant 1 Participant 2 Participant 1 Participant 2 Physical Well-Being Physical Well-Being Mental/Emotional Mental/Emotional Well-Being Well-Being Participant 1 Life Satisfaction Participant 2 Life Satisfaction Figure B2. This figure is separated by participant, domain, and pre-post test scores. A higher score indicates higher levels of well-being and satisfaction. MENTAL HEALTH AND CARE FOR VETERANS FROM HOMELESSNESS 18 Appendix C DCE Weekly Planning Guide Week DCE Stage (orientation, screening/evaluation, implementation, discontinuation, dissemination) 1 Orientation Screening/Evaluation Weekly Goal 1. Complete orientation by end of the week 2. Begin Needs Assessment and new literature review by end of the week Objectives Meet with site mentor and educate on why I am there and the purpose of my project and experience Discuss schedule and supervision plan with site mentor Understand site requirements and expectations Begin observing in the field to work towards experience goals and add to needs assessment information Begin new literature search Tasks Set up meeting with site mentor and other site personnel Begin working on new literature review Date complete 1/6/23 1/6/23 MENTAL HEALTH AND CARE FOR VETERANS FROM HOMELESSNESS 2 Cont Orientation Off-Site Time: Research- 32 hours 1. Complete Literature Review by end of the week 2. Complete Needs Assessment by end of week 3. Orient to OT group sessions by Thursday Complete entirety of literature review since change of project/site Finalize needs assessment questions Screening/Evaluation 1. Begin literature search for additional outcome measures for data collection 2. Start to create educational content for education and advocacy on role of OT 3. Administer 1 outcome measure with veteran participant 1 for pre intervention data (COPM was decided) Begin to compile a list of at least 5 evidence-based outcome measures to review for use 1/17/23 Ask for feedback on literature review Review MOU Observe 1st group session and take notes 3 Review findings and project purpose with site mentor 19 1/13/23 Set up time for Needs Assessment- complete and record Review notes on group 1/12/23 and reflect on how direction of the group regarding your project: mental health focus Write down key words of target outcomes measured and save/write down outcome measures as they are found 1/20/23 1/20/23 Meet with mentor to discuss site expectations of presentation Discuss with site mentor the best evidencebased outcome Create PowerPoint outline and begin to fill in content 1/18/23 Schedule time to see veteran and implement outcome measure MENTAL HEALTH AND CARE FOR VETERANS FROM HOMELESSNESS 4. Finalize MOU and review with site mentor 4 Screening/Evaluation Implementation measure for individual veteran based on chart review and personal experience Schedule meeting with site mentor to discuss capstone timeline and edit MOU 1. Observe social Observe and worker in the interview social field worker in the field to better understand their role on the interdisciplinary team 2. Complete literature search for Pick 1-2 additional evidence-based outcome outcome measures for data collection measures from the list of 5 to discuss with OT site mentor 3. Complete powerpoint presentation of educational content related Send presentation to to the role of OT at the site OT site mentor and when and for review how to refer to OT services 4. Begin compiling and reviewing literature from Finalize MOU Make a list of questions to discuss with social worker and take notes during visit to review and reflect on 20 1/20/23 1/23/23 1/27/23 Compile a list of at least 5 evidence-based outcome measures to review for use and begin to review Fill in outline with educational content and attach an accurate reference page Create outline for portfolio and separate 1/26/23 1/26/23 MENTAL HEALTH AND CARE FOR VETERANS FROM HOMELESSNESS literature review to create evidencebased mental health intervention portfolio Create separate folders for each evidence-based mental health intervention to put literature and other data 5 Screening/Evaluation 1. Complete evaluation and collect pre data on veteran participant 2 2. Continue 1st draft of evidencebased mental health intervention portfolio 3. Create rough draft of referral documents literature into correct intervention folders 1/24/23 5. Begin reviewing referral documentation 6. Complete Whole Health for Mental Health and WellBeing Certification course 21 Collect and compile referral documentation received from mentor Complete COPM and PHI on 1 veteran participant Complete 2 sections of EBP mental health intervention portfolio Create list of important referral Read all referral documentation and take notes on pros and cons of system as it stands- review this with OT site mentor and discuss purpose and direction for referrals Schedule evaluation session with veteran participant and document results and assessment Collect information from literature review and other resources to organize information into guide Compile, annotate, and review existing referral information 1/25/23 2/1/23 2/3/23 2/3/23 MENTAL HEALTH AND CARE FOR VETERANS FROM HOMELESSNESS 6 Screening/Evaluation Implementation 4. Continue progress on Homeless Populations certificate course 1. Finish evaluation on participant 1 2. Implement first individualized mental health session with veteran participant 1 3. Plan first individualized mental health session for veteran participant 2 4. Complete draft of evidence based mental health intervention portfolio information from prior documents and observationcompile into 1 concise referral document Ongoing Complete Personal Health Inventory with participant 1 Print and prepare Personal Health Inventory for completion Complete first session with participant 1 and complete note/record data Prepare materials for session: quiet recreation materials and PMR video 2/6/23 2/6/23 2/7/23 Document the plan for session 1, including list of materials needed and any references Complete remaining 3 sections 5. Complete final draft of referral sheet for presentation to Apply feedback and edit referral HUDVASH sheet team 6. Complete 1 evaluation and 22 Complete and compile research for session 1 planning related to results of assessment 2/10/23 Compile and review literature to put together content for remaining sections. Edit and consolidate information for the entirety of the guide 2/6/23 Present rough draft referral sheet to site mentor for feedback 2/8/23 MENTAL HEALTH AND CARE FOR VETERANS FROM HOMELESSNESS 1 treatment session in the field for increased clinical experience 7 Implementation 7. Continue progress on Homeless Populations certificate course 1. Present clinical conversation on the role of OT and their collaboration with social work to HUDVASH team 2. Present new OT referral sheet to HUDVASH team Identify 2 veterans to complete eval and treatment sessions with this week Complete script and practice for presentation Complete script to explain referral sheet most effectively to team 23 Chart review, prepare, and implement HUDVASH OT sessions Ongoing Determine with my site mentor the slides that I will be presenting, organize a script, practice out loud 2-3 times before presentation and ask for feedback Prep: 2/14/23 Completion: 2/15/23 Ask for finalized tech 2/15/23 version of referral sheet, review, organize script and practice out loud 2-3 times before presentation and ask 3. Implement Familiarize self for feedback 2/13interventions with possible 2/16/23 from MH Read through MH evidenceinterventions to intervention portfolio based MH use in general and gain a good intervention portfolio when practice and be understanding of prepared to indications and how to applicable grade interventions during veteran implement when applicable before use. Chart treatment during review and determine treatment good candidates each day 4. Continue progress on Ongoing Homeless Populations MENTAL HEALTH AND CARE FOR VETERANS FROM HOMELESSNESS 8 Implementation certificate course 1. Complete individualized mental health intervention sessions for participants 1 and 2 2. Implement interventions from evidencebased MH intervention portfolio when applicable during veteran treatment 3. Begin updating evidencebased mental health intervention portfolio 4. Continue progress on Homeless Populations certificate course 9 Implement 1. Implement interventions from evidencebased MH intervention portfolio when applicable Plan and implement sessions based on data and goals set at previous session Review evaluation data and goals and feedback from previous session- plan and add session details to intervention plan, implement session, and write progress notes Chart review and determine good candidates each day Continue to familiarize self with possible MH interventions to use in general practice and be prepared to implement when applicable during Administer treatment interventions and ask individuals for feedback on their Add additional experiences and record excerpts of for future use of data personal in portfolio experiences implementing interventions with individuals to the portfolio Continue to familiarize self with possible MH interventions to use in general practice and be prepared to implement 24 Plan: 2/21/232/22/23 Implement: 2/23/23 2/23/232/24/23 2/23/232/24/23 2/21/232/22/23 (remote) Ongoing Chart review and 2/27, 2/28, determine good 3/2/2023 candidates for intervention - Review current notes from implementation experiences MENTAL HEALTH AND CARE FOR VETERANS FROM HOMELESSNESS during veteran treatment 2. Begin planning next session for veteran participants 1 and 2 when applicable during treatment--focus on interventions that have not been tried yet Document the session plans, including list of materials needed and any references 3. Increase progress on Homeless Populations Course 10 Implementation 1. Complete next session plan for participant 1 and 2 Document the full session plan in individualized mental health plans for each participant, including list of materials needed and any references - and notice trends Review interventions that have not been tried yet and understand indications for use Complete and compile research for session planning related to results of assessment and experience from previous session Write down check in points to talk about with participant and print out/gather materials needed 25 3/1, 3/3/2023 Ongoing 3/10/23 3/8/23 MENTAL HEALTH AND CARE FOR VETERANS FROM HOMELESSNESS 2. Administer OT evaluation. 3. Increase progress on Homeless Populations 11 Implementation 1. Increased field Chart review experience individuals, assess whether they are appropriate for general mental health interventions and determine which ones2. Increased assist site progress on mentor with Homeless treatment Populations course 3. Begin dissemination Presentation 12 Implementation Complete thorough review of individual, assess referral sheet, and discuss with site mentor before administering evaluation 1. Complete final session with participant 1 Create concise and effective PowerPoint presentation for dissemination Plan and implement sessions based on data and 26 Chart review on individual, write down important information, print eval template for note taking Ongoing Gather materials for treatment after chart review and discuss treatment ideas and plans with site mentor 3/16/23 Remote: 3/13 and 3/17/23 (Ongoing) Create an outline of presentation and collect materials from DCE to use for reference to complete presentation. Prepare all tangible and online materials for session, write out 3/13/233/17/23 3/21/23 MENTAL HEALTH AND CARE FOR VETERANS FROM HOMELESSNESS Discontinuation 13 Discontinuation Dissemination 2. Complete final session with participant 2 3. Collect post data from participant 1 4. Collect post data from participant 2 5. Work on dissemination presentation 1. Present findings and general MH intervention guide to site mentor and HUDVASH COD administration 2. Dissemination Presentation to team 14 Dissemination *Offsite time: 40 hours 1. Poster Creation 2. Scholarly Report work goals set at previous session- have a plan for veteran retention in mental health practices following the completion of intervention programming Create concise and effective PowerPoint presentation for dissemination Present findings and general MH intervention guide to site mentor and educate on use session plan for reference 27 3/20/23 3/21/23 3/20/23 Fill in data/information on outline and slides created, cross-check references Schedule a time to meet with mentor, print and assemble tangible guide, print web version to PDF 3/27/23 and 3/30/23 3/28/23 Present findings to HUD-VASH supervisor and community outreach division director Create professional poster outlining DCE project for future use if/when presenting at state or national conferences Create script and complete 2-3 practice run throughs prior to presentation, proofread PowerPoint slides and references Gather all materials 4/7/23 from literature review, site dissemination, and project and experience outcomes for use when creating poster Apply prior feedback provided for each MENTAL HEALTH AND CARE FOR VETERANS FROM HOMELESSNESS 3. Public Dissemination presentation creation Assemble all pieces of scholarly report for submission for feedback Create professional PowerPoint to use for dissemination to the public via VoiceThread section of the scholarly report and assemble into one document Gather all materials from literature review, site dissemination, and project and experience outcomes for use when creating presentation 28  ...