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Virginia Occupational Therapy Association Conference October 26 th,2014 Twylla Kirchen, Ph.D., OTR/L and Jeanne Wenos, P.E.D. Occupational Therapy Program.

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Presentation on theme: "Virginia Occupational Therapy Association Conference October 26 th,2014 Twylla Kirchen, Ph.D., OTR/L and Jeanne Wenos, P.E.D. Occupational Therapy Program."— Presentation transcript:

1 Virginia Occupational Therapy Association Conference October 26 th,2014 Twylla Kirchen, Ph.D., OTR/L and Jeanne Wenos, P.E.D. Occupational Therapy Program James Madison University

2  Military enlisted soldier and officer in U.S. Army  Military spouse and mother for 16 years  Currently the Director of Rehabilitation for a state-funded veteran’s home

3  43% of male veterans are over the age of 60 (Katz, 2012)  1.8 million soldiers have deployed in combat operations in Iraq and Afghanistan  Approximately 30% will eventually reside in skilled nursing facilities after age sixty-five (Sorrell & Durham, 2011)

4 Gap In the Research Occupational therapy research focused on the ways in which military culture, occupation, heritage, or culture in general affect the relocation and adaptation of veterans from home to long-term care settings does not exist

5 Statement of Purpose The purpose of this research was to examine military culture through an occupation-based, cultural heritage lens, in relation to the adaptation of veterans relocating to long-term care settings

6 Research Description  Three-study, mixed method design  Resulted in the development and implementation of a military- focused, occupational-based, cultural heritage intervention with veterans who had recently relocated to a LTC setting

7 Conceptual Foundation This research was inspired by the by the work of the interdisciplinary team: Hersch, Hutchinson, Davidson, and Mastel-Smith which examined older adults’ adaptation to long term care using the Occupation- based Cultural Heritage Intervention (OBCHI) under grant # Grant No. R21NR008932 from the National Institute of Nursing Research  Hutchinson, S., Hersch, G., Davidson, H. A., Chu, A. Y., & Mastel-Smith, B. (2011)  Hersch, Hutchinson, Davidson, Wilson, Maharaj, and Watson, (2012)

8 Literature Review  Quality of Life in Long-term care  Adaptation in Long-term Care  Military Culture and Adaptation

9 Research Questions  Study 1: What person and environment factors emerge when veterans offer their perspectives about adaptation to long-term care?  Study 2: Based upon the perspectives of veterans on adaptation to long-term care, what are the essential components of an intervention protocol?  Study 3: Does the intervention improve the participants’ QOL, social participation and activity engagement?

10 Participants  Male Veterans between the ages of 60 and 92 years  Admitted to one long-term care within 12 months or less  Scored a 5 or better on a 10 point cognitive screen  Gave informed consent NOTE: Study 1 = 10 participants, Study 3 = 11 participants

11 Participant Demographics

12 Study One: Person and environment factors impacting veterans' adaptation to long-term care: A qualitative study The purpose of this study was to investigate person and environment factors of aging veterans that facilitated relocation and adaptation to long-term care facilities

13 Research Design Qualitative Phenomenological Approach  explores how aging veterans perceive their experience and transforms those perceptions into reality (Patton, 2001)  phenomenon examined in this study was adaptation in relation to culture, heritage, occupation, and specifically, military culture

14 Methodology  Data collection took place over a 4-week time-frame  Three trained graduate assistants conducted interviews  Interviews were audio-recorded and transcribed verbatim by the graduate student and/or a professional company

15 Eliminating Bias  Epoche (bracket data in pure form relating to the phenomenon being examined)  Interpret the meaning of the phrases  Clarify with participant  Identify recurring themes  Themes are clustered and over arching themes are agreed upon by a panel of experts.

16 Findings (Primary Themes) 1. Family 2. Home 3. Military Occupation/Job 4. Spirituality 5. Leisure Activities 6. Food/Music in relation to Celebrations NOTE: All themes were interwoven by military culture

17 Conclusions/Implications  Participants expressed a need to be able to interact with other residents who are cognitively intact.  Despite physical impairment, the participants in this study expressed a desire to have some sense of control over their lives and routines.  Participants would like to be offered choices, especially for food and activities.

18 Study Two: Development of the Occupation- based Cultural Heritage Intervention- Military Version (OBCHI-MV) Protocol Manual  The purpose of this study was to develop a military-focused, occupational-based, cultural heritage intervention for veterans who had recently relocated to a LTC setting.  This study captured the unique cultural needs of aging veterans that emerged qualitatively into an intervention group protocol.

19 Study Aims This study incorporated the themes that emerged from study one, into a military-focused, occupation-based, cultural heritage intervention, which consisted of 6 protocol-driven group sessions

20 Study Two: Research Question Based upon the perspectives of veterans on adaptation to long-term care, what are the essential components of an intervention protocol?

21 Study Two: Methodology  Six overarching themes from Study One were used to develop six protocol-driven group sessions  A panel of experts reviewed the manual and consensus was reached on all aspects of the protocol prior to implementation

22 Theoretical Bases for the Group Sessions  Group Dynamics(Schwartzberg, Howe, & Barnes, 2008)  Effectance Motivation (White, 1959)  Needs Hierarchy (Maslow, 1970)  Purposeful, occupation-based cultural activities (Schwartzberg, Howe, & Barnes, 2008)  Csikszentmihalyi (1990) as a “flow state”  “Adaptation through occupation,” (Reed, 1984)

23 Administration of the OBCHI-MV  OBCHI-MV is intended to be used in conjunction with the Military Culture and Lifestyle Interview for Long-term Care- Interview Guide (Kirchen, 2013)  Activity and therapy departments, as well as social workers, could foreseeably use the OBCHI-MV to facilitate adaptation of veterans to LTC

24 Study Three: Evaluating the effectiveness of the Occupation- based Cultural Heritage Intervention-Military Version (OBCHI- MV): A Quantitative Study This third study evaluated the effectiveness of the Occupation-based Cultural Heritage Intervention-Military Version (OBCHI-MV) in improving activity engagement, quality of life and social participation of veterans residing in long-term care settings.

25 Specific Aims This study implemented the OBCHI-MV (intervention) and determined via pre- and post-tests whether or not the intervention improved participants’ quality of life (QOL), activity engagement and social participation.

26 Study Three: Research Question Does the intervention improve the participants’ QOL, social participation and activity engagement?

27 Participant Selection  Inclusion/Exclusion Criteria was the same as for Study One  The sample was divided into two groups: the first group had five participants and the second group had six participants, for a total of eleven participants.

28 Tools

29 Data Analysis  Wilcoxon Signed Rank Sum Test (the non-parametric equivalent of a dependent samples t-test)  Used when the relative magnitude of changes and the direction of the changes in the data are of primary interest (Kielhofner, 2006)  Power analysis was used to calculate the effect size of each pre- and post-test tool.  The effect size is the mean difference in terms of the standard deviation  Pre- and post- intervention changes were considered meaningful when they were either statistically significant at p <.05 or they suggested moderate effect sizes (d )  Small is d=.20, Medium is d=.50 and Large is d=.80 (Kielhofner)

30 Results

31 Interpretation Data analysis revealed marginally significant improvement (p =.08) and moderate effect size (Cohen’s d=0.74) of the Standard Form-12, Physical Component Score, which indicated participants felt healthier post-intervention The Quality of Life Index (Psychological and Family Subtests) depicted a trend towards being clinically significant; however change from pre-test to post-test was not statistically significant for any of the measures (all ps >.05)



34 Clinical Implications  Sense of Home  Time Use (Choices and Control)  Leisure Activities  Social Participation  Continuity of Life Roles

35 Limitations  Small sample size and lack of a control group  Homogeneity of gender amongst the participants  Another limitation may have been the age span of the participants  All participants were housed in the same facility The outcomes may have been more valid if participants were recruited from a variety of veteran homes  The data analysis may have revealed more significant results if the intervention consisted of additional group sessions. Three weeks may not have been a long enough timeframe to measure the effectiveness of the intervention

36 Future Research  Replicate the study with a larger, more geographically diverse sample  Examine the benefits of the OBCHI-MV over time (Longitudinal Study)  Implement the OBCHI-MV with the Wounded Warrior population  Isolate and Examine Environmental Influence on Adaptation of Veterans in LTC  Isolate and Examine Military Cultural influence on Adaptation of Veterans in LTC

37 Research Question Review Summary of Findings The findings of this study indicate the OBCHI-MV has the potential to improve quality of life, activity engagement and social participation for veterans who have recently transitioned to long-term care

38 Thank you:  Dr. Hersch, Dr. Evans, Dr. Pickens and Ms. Susan Copolla  Rachel Warren, OTS, UNC Chapel Hill Research Assistants  Veterans-for trusting me to ensure your voices are heard

39 Questions/Comments

40 References: Csikszentmihalyi, M. (1990). Flow: The psychology of optimal experience. NY: Harper Collins. Ferrans, C. E., & Powers, M. J. (1992). Psychometric assessment of the Quality of Life Index. Research in Nursing and Health, 15, 29–38. Frank, G. (1996). The concept of adaptation as a foundation for occupational science research. In R. Zemke & F. Clark (Eds.), Occupational Science: The evolving discipline (pp. 47-55). Philadelphia: F. A. Davis. Guse, L. W., & Masesar, M. A. (1999). Quality of life and successful aging in long-term care: Perceptions of residents. Issues in Mental Health Nursing, 20(6), 527-539. Hasselkus, B. R., & Murray, B. J. (2007). Everyday occupation, well-being, and identity: The experience of caregivers in families with dementia. American Journal of Occupational Therapy, 61(1), 9-20. doi:10.5014/ajot.61.1.9 Hersch, G., Spencer, J., & Kapoor, T. (2003). Adaptation by elders to new living arrangements following hospitalization: A qualitative, retrospective analysis. Journal of Applied Gerontology, 22(3), 315-339. doi: 10.1177/0733464803253586 Hersch, G., Hutchinson, S., Davidson, H., Wilson, C., Maharaj, T., & Watson, K. B. (2012). Effect of an occupation-based cultural heritage intervention in long-term geriatric care: A two-group control study. American Journal of Occupational Therapy, 66(2), 224-232. doi: 10.5014/ajot.2012.002394 Hutchinson, S., Hersch, G., Davidson, H. A., Chu, A. Y., & Mastel-Smith, B. (2011). Voices of elders: Culture and person factors of residents admitted to long-term care facilities. Journal of Transcultural Nursing: Official Journal of the Transcultural Nursing Society / Transcultural Nursing Society, 22(4), 397-404. Katz, I. R. (2012). Geriatric psychiatry in the department of veterans affairs: Serving the needs of aged and aging veterans. The American Journal of Geriatric Psychiatry, 20(3), 195-198. doi: 10.1097/JGP.0b013e3182435f00 Kielhofner, G., 1949-. (2006). Research in occupational therapy : Methods of inquiry for enhancing practice F.A. Davis; F a Davis Co, Attn: Jacki Albertini, 1915 Arch st, Philadelphia, PA, 19103.

41 References: Maslow, A. H. (1970). Motivation and personality (2 nd ed.). NY: Harper & Row. Moos, R. H., & Lemke, S. (1984). Sheltered Care Environment Scale Ideal Form (SCES– I). In Multiphasic Environ- mental Assessment Procedure manual (Appendix A). Palo Alto, CA: Social Ecology Laboratory, Veterans Administration, and Stanford University Medical Center. Patton, M. (2002). Qualitative evaluation and research methods (3rd ed.). Newbury Park: Sage. Pfeiffer, E. (1975). A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. Journal of the American Geriatrics Society, 23, 433–441. Reed, K. L. (1984). Models of practice in occupational therapy. Baltimore: Williams & Wilkins. Reilly, M. (1962). The Eleanor Clarke Slagle: Occupational therapy can be one of the great ideas of 20th century medicine. AJOT 17(1), 1-9. Schnelle, J. F., Rahman, A., Durkin, D. W., Beuscher, L., Choi, L., & Simmons, S. F. (2013). A controlled trial of an intervention to increase resident choice in long term care. Journal of the American Medical Directors Association, 14(5), 345-351. doi:10.1016/j.jamda.2012.11.013 Schultz, S., & Schkade, J. K. (1992). Occupational adaptation: Toward a holistic approach for contemporary practice, part 2. The American Journal of Occupational Therapy: Official Publication of the American Occupational Therapy Association, 46(10), 917-925. Schultz, S., & Schkade, J. (1997). Adaptation. In C. Christian- sen & C. Baum (Eds.), Occupational therapy: Enabling function and well-being (2nd ed., pp. 458–481). Thoro-fare, NJ: Slack. Schwartzberg, S. L., Howe, M. C., & Barnes, M. A. (2008). Groups: Applying the functional group model. Phila: F. A. Davis. Settersten, R. A. J. (2006). When nations call: How wartime military service matters for the life course and aging. Research on Aging, 28(1), 12-36. Sheppard, S. C., Malatras, J. W., & Israel, A. C. (2010). The impact of deployment on U.S. military families. American Psychologist, 65(6), 599-609. Sorrell, J. M., & Durham, S. (2011). Meeting the mental health needs of the aging veteran population. Journal of Psychosocial Nursing and Mental Health Services, 49(1), 22-25. doi: 10.3928/02793695-20101207-01 White, R. W. (1959). Motivation reconsidered: The concept of competence. The Psychological Review, 271-274. Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5 th ed.) NY: Basic Books. Yerxa, E. J. (1967). 1966 Eleanor Clarke Slagle Lecture. Authentic occupational therapy. AJOT, 22, 1, 1-9.

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