Virginia Occupational Therapy Association Conference October 26th,2014 Twylla Kirchen, Ph.D., OTR/L and Jeanne Wenos, P.E.D. Occupational Therapy Program James Madison University Military enlisted soldier and officer in U.S. Military spouse and mother for 16 years Army Currently the Director of Rehabilitation for a state-funded veteran’s home 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) 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 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 Research Description Three-study, mixed method design Resulted in the development and implementation of a militaryfocused, occupational-based, cultural heritage intervention with veterans who had recently relocated to a LTC setting 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 Occupationbased 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) Literature Review Quality of Life in Long-term care Adaptation Military in Long-term Care Culture and Adaptation 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? 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 Participant Demographics 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 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 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 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. Findings (Primary Themes) 1. 2. 3. 4. 5. 6. Family Home Military Occupation/Job Spirituality Leisure Activities Food/Music in relation to Celebrations NOTE: All themes were interwoven by military culture 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. Study Two: Development of the Occupationbased Cultural Heritage InterventionMilitary 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. 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 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? 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 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) Administration of the OBCHI-MV OBCHI-MV is intended to be used in conjunction with the Military Culture and Lifestyle Interview for Long-term CareInterview 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 Study Three: Evaluating the effectiveness of the Occupationbased Cultural Heritage Intervention-Military Version (OBCHIMV): 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. 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. Study Three: Research Question Does the intervention improve the participants’ QOL, social participation and activity engagement? Participant Selection Inclusion/Exclusion as for Study One The Criteria was the same 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. Tools 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) Results 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) Clinical Implications Sense of Home Time Use (Choices and Control) Leisure Activities Social Participation Continuity of Life Roles 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 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 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 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 Questions/Comments References: Csikszentmihalyi, M. (1990). 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