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Adaptation of Veterans to Long-Term Care: the Impact of Military Culture a Dissertation Submitted in Partial Fulfillment Of ADAPTATION OF VETERANS TO LONG-TERM CARE: THE IMPACT OF MILITARY CULTURE A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY IN THE GRADUATE SCHOOL OF THE TEXAS WOMAN’S UNIVERSITY SCHOOL OF OCCUPATIONAL THERAPY COLLEGE OF HEALTH SCIENCES BY TWYLLA KIRCHEN, B.A., M.S. DENTON, TEXAS DECEMBER 2013 Copyright © Twylla Kirchen, 2014 all rights reserved. iii DEDICATION For the amazing veterans who shared their stories and time, we will be forever grateful for your selfless sacrifice. iv ACKNOWLEDGEMENTS I would like to acknowledge the individuals who supported the completion of this dissertation. I especially want to thank Dr. Gayle Hersch for her willingness to share her work on the Occupation-based Cultural Heritage Intervention. Her dedication to improving quality of life for residents in long-term care settings inspired me to pursue this study. The research design was adapted from work by 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. I would also like to thank Rachel Warren, Occupational Therapy Student from UNC, Chapel Hill. Rachel managed the operational aspects of the study. Her superb organizational skills were the reason we were able to initiate and complete the study in a timely manner. I would like to acknowledge my research assistants, Melissa Kurian, Zilfa Ong, Frank and Michelle Dy, Brandon Noel, Jennifer Basurto and Rebekka Wetten- Goldstein. In addition, I would like to thank my research committee members, Dr. Anlee Evans, Dr. Noralyn Pickens, Susan Coppola and Dr. Gayle Hersch. You challenged me to critically think about the research design and the application of the results for long-term care settings. Finally, I want to thank my family: my husband Erik and children Cole and Meghan for their support and patience. v ABSTRACT TWYLLA KIRCHEN ADAPTATION OF VETERANS TO LONG-TERM CARE: THE IMPACT OF MILITARY CULTURE DECEMBER 2013 The purpose of this mixed-methods study was to develop and implement a military cultural group intervention that would facilitate veterans’ adaptation to long-term care residential settings. Eleven male veterans residing in a state-funded veteran’s home between the ages of 60 to 92 years participated in the study. The research team obtained participant informed consent, screened, interviewed, coded interviews, identified themes and developed a protocol-driven intervention based on the emergent themes. The participant interviews revealed specific person and environment factors that veterans value when transitioning to long-term-care. A protocol manual entitled, Occupation- based Cultural Heritage Interview-Military Version (OBCHI-MV) was designed based on these participant-identified topics. The manual incorporated music, food, leisure activities, etc. to meet the specific needs of the participants and was used to facilitate a six-session group intervention. Pre- and post-tests measuring activity engagement, social participation and quality of life were administered to measure the effectiveness of the intervention. Data analysis using the Wilcoxon Signed Rank Test revealed marginally significant improvement (p = .08) and moderate effect size (Cohen’s d=0.74) vi 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 clinical meaningful, however change from pre-test to post-test was not statistically significant for any of the measures (all ps > .05). The unifying element for group cohesion was military culture. In isolation, data analysis of the pre- and post-test mean scores were not significant; however, when coupled with participant interviews, results from the Yesterday Interview (YI) and Post-Intervention Participant Survey, 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. vii TABLE OF CONTENTS Page COPYRIGHT ............................................................................................................. iii DEDICATION ............................................................................................................ iv ACKNOWLEDGMENTS ............................................................................................ v ABSTRACT ................................................................................................................ vi LIST OF TABLES ...................................................................................................... xi LIST OF FIGURES ................................................................................................... xii Chapter I. INTRODUCTION ............................................................................................... 1 Statement of the Problem ................................................................................. 1 Call for Research .............................................................................................. 2 Statement of the Purpose .................................................................................. 2 Premise for the Intervention ............................................................................. 3 Occupational Adaptation and OBCHI-MV ...................................................... 4 Specific Aims ................................................................................................... 5 Researcher’s Perspective .................................................................................. 6 II. BACKGROUND AND SIGNIFICANCE ........................................................... 7 Method of Literature Search ............................................................................. 8 Occupational Therapy Interventions in Long-term Care .................................. 9 Occupational Therapy Interventions and Well-being of Older Adults ........... 10 Quality of Life in Long-term Care ................................................................. 11 Adaptation and LTC ....................................................................................... 12 Military Culture and Adaptation .................................................................... 13 Summary of Findings ..................................................................................... 14 viii III. STUDY ONE ..................................................................................................... 16 Statement of the Problem ............................................................................... 16 Statement of the Purpose ................................................................................ 17 Definition of Terms ........................................................................................ 17 Researcher’s Perspective ................................................................................ 18 Background and Significance ......................................................................... 19 Methods .......................................................................................................... 24 Tools ............................................................................................................... 25 Data Collection ............................................................................................... 26 Data Analysis .................................................................................................. 27 Trustworthiness Techniques ........................................................................... 29 Findings .......................................................................................................... 30 Person Factors ................................................................................................ 30 Environment Factors ...................................................................................... 33 Discussion ....................................................................................................... 42 Implications for Long-term Care Facilities .................................................... 42 Conclusion ...................................................................................................... 46 IV. STUDY TWO ................................................................................................... 48 Statement of the Problem ............................................................................... 48 Statement of the Purpose ................................................................................ 49 Description and Rationale for Intervention (OBCHI-MV) Methods ............. 50 Description and Rationale for Group Facilitator Role ................................... 50 Specific Aims ................................................................................................. 51 Researcher’s Perspective ................................................................................ 51 Background and Significance ......................................................................... 52 Occupational Therapy Intervention in Long-term Care ................................. 54 Occupational Therapy Interventions and Wellbeing
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