Adaptation of Veterans to Long

Virginia Occupational Therapy
Association Conference
October 26th,2014
Twylla Kirchen, Ph.D., OTR/L
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
 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
 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
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
Male Veterans between the ages of 60 and 92
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
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
 Data
collection took place over a 4-week
 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
 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
Findings (Primary Themes)
Military Occupation/Job
Leisure Activities
Food/Music in relation to Celebrations
NOTE: All themes were interwoven by military
Participants expressed a need to be able to
interact with other residents who are cognitively
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
 This study captured the unique cultural
needs of aging veterans that emerged
qualitatively into an intervention group
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
Study Two: Research Question
Based upon the perspectives of
veterans on adaptation to long-term
care, what are the essential
components of an intervention
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
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,
Csikszentmihalyi (1990) as a “flow state”
“Adaptation through occupation,” (Reed,
Administration of the
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
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.
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
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
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
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.
Maslow, A. H. (1970). Motivation and personality (2nd 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 (5th ed.) NY: Basic Books.
Yerxa, E. J. (1967). 1966 Eleanor Clarke Slagle Lecture. Authentic occupational therapy. AJOT, 22, 1, 1-9.