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

TWYLLA KIRCHEN, B.A., M.S.

DENTON, TEXAS

DECEMBER 2013

iii

DEDICATION

For the amazing veterans who shared their stories and time, we will be forever grateful for your selfless sacrifice.

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.

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.

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TABLE OF CONTENTS

Page

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 of Older Adults ...... 55 Adaptation in LTC ...... 55 Military Culture and Adaptation ...... 56 Methods ...... 58 Data Collection Procedures ...... 58 Trustworthiness of the OBCHI-MV Protocol Manual ...... 59 Theoretical Bases for the Group Intervention ...... 59 Results ...... 61 Sample ...... 62 Theme-based Module Development ...... 63 Discussion ...... 76 Administration of the OBCHI-MV (Non-research Version) ...... 77 Limitations ...... 78 ix

Summary ...... 78

V. STUDY THREE ...... 80

Statement of the Problem ...... 80 Statement of the Purpose ...... 81 Definition of Terms ...... 81 Premise for the intervention ...... 82 Specific Aims ...... 83 Background and Significance ...... 83 Quality of Life in Long-term Care ...... 84 Adaptation and LTC ...... 85 Military Culture and Adaptation ...... 86 Research Design ...... 87 Environmental Component of the Intervention ...... 87 Participant Selection ...... 89 Tools ...... 90 Data Collection Procedures ...... 92 Managing Bias and Securing Data ...... 92 Data Analysis ...... 93 Results ...... 93 Sample ...... 94 Findings ...... 95 Descriptions of Results from Each Tool ...... 96 Post-Intervention Feedback Surveys ...... 99 Military-Focused Group Sessions ...... 101 Discussion ...... 102 Sense of Home ...... 103 Limitations ...... 107 Conclusion ...... 108

VI. DISCUSSION ...... 109

Introduction ...... 109 OBCHI-MV and Adaptation ...... 110 Occupational Adaptation and the OBCHI-MV ...... 111 Authentic Occupational Therapy ...... 113 Implications for Profession of Occupational Therapy ...... 114 Limitations/Lessons Learned ...... 116 Directions for Further Research ...... 118 Summary ...... 119

REFERENCES ...... 121

APPENDICES

A. Military Culture and Lifestyle Interview for Long-term Care ...... 128 B. Life Narrative/Cultural Heritage Interview Guide Revised ...... 130 C. SCES Personal Growth Questions ...... 133 D. SF-12 ...... 135 E. Quality of Life Index-Nursing Home Version ...... 138 F. Short Portable Memory Status Questionnaire (SPMSQ) ...... 143 G. Yesterday Interview (YI) ...... 146 H. Geriatric Depression Scale (GDS) ...... 148 I. Occupation-based Cultural Heritage Intervention-Military Version (OBCHI-MV) Protocol Manual ...... 150 J. IRB Approval Letter ...... 210

LIST OF TABLES

Table Page

1. Table 1A ...... 25

2. Table 1B ...... 62

3. Table 1C ...... 94

4. Person and Environment Factors ...... 35

5. Pre- and Post-Test Tool Description ...... 90

6. Means and Standard Deviations of Outcome Variables at Baseline and

Post Intervention by Results of Wilcoxon Signed Rank Sum Test

(N=11) ...... 96

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LIST OF FIGURES

Figure Page

1. Two WWII Veterans get Acquainted ...... 76

2. Photos of the Multisensory Intervention Environment ...... 88

2. Pre and Post-test Use of Leisure Time ...... 99

3. Participant Post Interview Feedback ...... 100

4. Diagram of the Occupation-Based Cultural Heritage Intervention-

Military Version ...... 112

xiii

CHAPTER I

INTRODUCTION

Statement of the Problem

Currently, 43% of male veterans are over the age of 60, (Katz, 2012). In addition,

1.8 million soldiers have deployed in combat operations in Iraq and Afghanistan since

2003, some as many as five times. Thousands of younger veterans will require specialized care as they age, and approximately 30% will eventually reside in skilled nursing facilities after age sixty-five (Sorrell & Durham, 2011).

Sorrell and Durham (2011) state the Veteran Affair’s Medical Center’s long-term care facilities cannot meet overwhelming current demands and provide support for veterans with cognitive and physical deficits who can no longer be cared for at home.

They note it is imperative that immediate measures be taken to strengthen resources for research, manpower, and training to accommodate the relocation of aging veterans from home to long-term care (LTC).

Department of Veterans Affairs, 2012). Nevertheless, 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.

Call for Research

Relocation to long-term care often marginalizes life roles of the veteran. For example, he may have been a pet owner or gardener; however once he transitions to the

LTC facility he no longer fulfills these roles. In addition, deficits in person systems such as psychosocial, cognitive or sensorimotor may lead to maladaptive behaviors, (Schultz

& Schkade, 1997). Many veterans who reside in LTC facilities feel as if family members have left them there to die and as if they have no purpose in life, (Katz, 2012). Because long-term care facilities are usually the last home for aging veterans, it is imperative that quality of life of veterans improves within this setting, not only for the current population, but also for the future 330,000 service members who will reside in LTC, (U.S.

Department of Health and Human Services, 2013).

Statement of the Purpose

The purpose of this dissertation 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. Military culture for the purposes of this study was defined as; the manner in which military experiences shape an individual’s worldview,

(Kirchen, 2013). Military experiences influence the perspective of both the service member and his or her immediate and extended family. For example, on average, a military family relocates every two to three years, (Adler & Castro, 2013). They may

live overseas and seldom live near extended family members, (Adler & Castro).

Therefore, the worldview of a military family may be quite different than that of family who has lived in one geographical location for many generations.

Occupation-based is defined as the therapeutic use of activity within the participant’s natural environment supported by the belief that human engagement in meaningful, purposeful activities is essential to health and wellbeing, (Reilly, 1962).

Hersch et al., (2012), defined cultural heritage as; the learned beliefs, customs, actions, communication and life ways of a person. A veteran’s cultural heritage may be influenced by childhood traditions, religious beliefs or other life experiences that shape the unique person who he or she has become. Military culture and cultural heritage are distinguished for the purpose of this study by associating person factors with military experience as military culture and those person factors unrelated to the military as one’s cultural heritage.

Premise for the Intervention

The dissertation consisted of a three-study, mixed method design, which resulted in the development and implementation of a military-focused, occupational-based, cultural heritage intervention (OBCHI-MV) with veterans who had recently relocated to a

LTC setting. The basic premise for the intervention was that an individual’s culture empowers the person with meaningful rituals and beliefs which, given the opportunity, can be expressed and shared with others in a supportive social system. By engaging veterans/residents in small group interactions and meaningful activities based on their

cultural traditions (both military and heritage based), a sense of connection with other group members can be fostered. By implementing the OBCHI-MV during the relocation period (within twelve months of the resident’s admission), the cultural heritage and military culture of each individual in the group is highlighted to promote the person’s adaptation to the facility. Measurement of the resident’s social participation, activity engagement, and quality of life are used to determine the level of adaptation. Hersch et al., (2012) defined adaptation as a normal process in which a person encounters a perceived challenge in the environment and successfully manages that challenge. This dissertation captured the unique cultural needs that exist specifically amongst aging veterans. When staff members obtain a better understanding and appreciation for a specific veteran’s cultural heritage and military experience, a symbiotic relationship develops that facilitates adaptation of the veteran to LTC.

Occupational Adaptation and OBCHI-MV

The OBCHI-MV provides a client-centered intervention that encourages the veteran to become the change agent in his new environment. The veteran guides and teaches the group facilitator about himself (cultural heritage) and military culture in general. This dynamic social exchange between veteran and staff member facilitates positive adaptive response modes in the veteran, which can lead to mature adaptive response behaviors and ultimately adaptation. Adaptive response modes are defined as patterns of responding to environmental cues that an individual develops in order to

overcome an obstacle or challenge (Schultz & Schkade, 1997). Active adaptation is measured by improved quality of life, social engagement and activity participation.

Specific Aims

Study 1 Person and environment factors impacting veterans' adaptation to long- term care: A qualitative study.

The first study investigated person and environment factors of aging veterans that facilitated relocation and adaptation to long-term care facilities. The research question for this study was as follows: What person and environment factors emerge when veterans offer their perspectives about adaptation to long-term care?

Study II Development of the Occupation-based Cultural Heritage Intervention-

Military Version (OBCHI-MV) Protocol Manual.

The second 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. This study answered the following research question:

Based upon the perspectives of veterans on adaptation to long-term care, what are the essential components of an intervention protocol?

Study III Evaluating the effectiveness of the Occupation-based Cultural Heritage

Intervention-Military Version (OBCHI-MV).

The third study implemented the intervention and determined through pre- and post-tests whether or not the intervention improved participants’ quality of life (QOL), activity engagement and social participation. The third study answered the following

research question: Does the intervention improve the participants’ QOL, social participation and activity engagement?

Researcher’s Perspective

My research focus was military culture in relation to adaptation of aging veterans to long-term care settings. I believe occupational therapists have an opportunity to conduct research that will guide practice and set the precedent for long-term care of veterans, both now and for years to come. I feel passionate about this topic because I was an enlisted soldier, an officer in the United States Army, and have been a military spouse and mother for the past sixteen years. In addition, I am currently the rehabilitation director for a state-funded veteran’s home in southeastern United States. I have experienced the benefits and challenges of military culture from multiple perspectives across the lifespan. I believe that experience gives me special understanding of these veterans and the issues they face as they relocate to long-term care facilities.

CHAPTER II

BACKGROUND AND SIGNIFICANCE

Katz, (2012), a medical doctor at the Department of Veteran’s Affairs, states as of the end of 2010, 33% of America's living veterans had served during the Vietnam War era, 9% during World War II, 11% during the Korean War, and 25% during the Gulf War era that began in 1990. At the end of 2010, 43% of the veteran men were older than 65 years old and 58% older than 60 years. Katz, (2012), emphasizes that veterans are distinguished by their history of service to their country, their training, and their membership in the unique culture shared by those in the profession of military service.

Due to combat exposure, veterans experience service-related mental and physical suffering and disability that differs from the civilian population. The disabilities experienced by veterans, coupled with the aging process, affect veterans in different ways at different periods in their lives. Katz contends that because veterans are part of a unique culture, the aging process for veterans must be studied and understood in a distinct manner from the civilian aging population.

advanced old age and younger veteran populations move into old age. The profession of

occupational therapy has the potential to significantly improve the quality of care for

aging veterans through research and practice. Nevertheless, occupational therapy

literature focusing on veteran adaptation to long-term care settings is currently non-

existent.

Method of Literature Search

Four specialist databases were searched between 28 August and 4 October 2012 including: Medline, PSYCHINFO, CINAHAL, ERIC and the Cochrane Database of

Systematic Reviews. Key search words used were; occupational therapy, adaptation, long- term care, nursing homes, aging, older adults, intervention and veterans.

Initially, the purpose of this literature review was to locate current occupational

therapy research within the past five years, which examined the transition of veterans to

long-term care settings. However, when no occupational therapy-specific literature could

be found on this topic, the literature search was expanded to include literature of other

disciplines to include, nursing, social work, etc. Similarly, when little to no research

could be found specifically addressing “veteran” transition to long-term care, the search

was expanded to include transition of “older adults” in general, to long-term care and

“effectiveness of occupational therapy interventions with older adults”. In addition,

research emphasizing the use of military culture to facilitate adaptation of soldiers to the

civilian sector was also reviewed.

Occupational Therapy Interventions in Long-term Care

Hutchinson et al., (2011), used a phenomenological, qualitative approach with a multiethnic, multidisciplinary team composed of nursing and occupational therapy (OT) faculty and graduate students to investigate person and environment factors of elders that facilitated adaptation to long-term care facilities. The participants consisted of 23 elders from six LTC settings. The interviews lasted from one to three hours. Participants were

Caucasian and African American. The findings revealed the following themes; spirituality, death, dying and philosophy of life, life experiences with change, cultural heritage, health, ethnicity, social support, LTC facility relationships, LTC facility maintenance and LTC support of personal growth. Comparison of African American and

Caucasian participants revealed more similarities than differences. The study suggested by implementing the Occupation-based Cultural Heritage Intervention (OBCHI) during the relocation period the cultural heritage of each individual in the group would be highlighted to promote the person’s adaptation to the facility.

Hersch, Hutchinson, Davidson, Wilson, Maharaj, and Watson, (2012), suggest that culture has an influential role in helping older adults adapt to life in long-term care facilities. Hersch et al., (2012), developed a group, cultural intervention to assist elders in adjusting to their new residential situation. The basic premise for the intervention was that an individual’s culture empowers the person with meaningful rituals and beliefs which, given the opportunity, can be expressed and shared with others in a supportive social system. By engaging residents in small group interaction and meaningful

occupations, based on their cultural traditions, a sense of connection with other group members could be fostered.

The method of the study was a quasi-experimental, nonequivalent, control group design. Twenty-nine participants were given pre- and post-tests. Residents in the intervention group received a 4-week, cultural protocol-driven intervention and were compared to the control group, who participated in groups with typical content such as crafts, etc. Measurement of the resident’s social participation, activity engagement, and quality of life was used to determine the level of adaptation. The results of the study revealed the effectiveness of a structured, occupation-based, group intervention that improved quality of life for participants. There were no significant differences, however, between the control and intervention groups.

Occupational Therapy Interventions and Well-being of Older Adults

One of the primary outcomes of this dissertation was to develop an occupation- based, cultural heritage intervention that would facilitate adaptation of veterans to long- term care. Occupational therapy interventions have been effective in promoting the wellbeing of independent-living older adults as evidenced in the work of Clark et al., (2012).

In this study, 460 men and women aged 60 to 95 years participated in a randomized controlled trial comparing an occupational therapy intervention to a no control condition over a six- month period. Results revealed that the intervention group showed favorable change scores when compared to the control group in the areas of pain, vitality, social functioning, mental health, composite mental functioning, life satisfaction and

depression. The findings indicate that the intervention has the potential to assist in the reduction of health decline and increase wellbeing in older adults.

Quality of Life in Long-term Care

Social isolation, environmental deprivation, and a lack of meaningful occupation can intensify depression and other disabilities in older adults (McKenna, Broome, &

Liddle, 2007). The transition and adaptation of older adults to LTC settings can often disrupt one’s daily routine and access to meaningful occupations and can lead to increased depression and decreased quality of life, (Hersch et al., 2012). Guse and

Masesar, (1999) explored factors related to quality of life and successful aging in LTC from the perspective of residents. This qualitative study revealed two themes as being important to quality of life for older adults who resided in LTC: enjoying nature and being helpful to others. McKenna, Broome and Liddle, (2007) examined time use in relation to role participation and life satisfaction in older adults aged 65 and older. The study was conducted within the community setting. It suggested older adults’ occupations and roles are diverse and age does not reduce occupational or role engagement. The study concluded that facilitating participation in valued roles was important to an older adult’s quality of life.

Long-term care settings are the last home for approximately 30 to 40% of the aged, (U.S. Department of Health and Human Services, 2013). As more aging veterans transition to long-term care settings, it becomes important to understand the unique physical, psychological, social and cultural aspects of caring for military personnel.

Literature suggests that “being understood” and “feeling connected” to a facility is a key aspect of adaptation for older adults in LTC settings (Brandburg, 2007; Brooker, Woolley

& Lee, 2007; Guse and Masesar, 1999; Moore, Delaney & Dixon, 2007; Sorrell &

Durham, 2011). Therefore, research is needed to better understand the specific needs of veterans who transition to LTC facilities.

Adaptation and LTC

Relocating from one’s home to long-term care involves adaptation because it includes leaving behind family, friends, routines, community groups, pets etc. The concept of adaptation has been used in OT research and practice as a means and an end when providing authentic occupational therapy, (Frank, 1996; Schultz & Schkade, 1997;

Yerxa, 1967). Adaptation can be defined as a person’s relationship with his or her environmental context, (Lawton & Nahamow, 1973). Adaptation for the purposes of this study was defined as the process by which a veteran encounters a perceived challenge in his environment and successfully manages that challenge as measured by increased quality of life, activity engagement and social participation, (Hersch et al., 2012).

According to recent research, indicators of successful adaptation to LTC include: having one’s care needs met, developing a sense of identity, having social connections, experiencing continuity of lifestyle and maintaining a sense of control over one’s life

(Bol, & MacMaster, 2003; Chao et al., 2008; Hersch et al., 2004). However, research that examines factors facilitating veteran-specific adaptation to LTC settings is not readily

available, but it’s likely that these same indicators for older adults may be applied to an aging veteran population.

Military Culture and Adaptation

When one relocates from one setting to another setting, he or she attempts to assimilate his or her cultural practices and beliefs into the new setting. Hersch et al.,

(2012), propose that the more successful the resident is with incorporating his or her cultural heritage into the long-term care environment, the higher the quality of life, activity engagement and social participation will be for that particular individual.

Military culture, as well as, cultural heritage must be better understood and incorporated into treatment in order to facilitate successful adaptation of veterans to long-term care settings.

Adler and Castro, (2013), U.S. Army psychologists, developed a model entitled the Occupational Mental Health Model (OMHM), a modification of the Soldier

Adaptation Model (SAM), (Bliese & Castro, 2003). The OMHM clarifies the occupation of being a soldier. Alder and Castro state that in order to treat physical and psychological issues of redeploying soldiers, one must understand the military context from the perspective of the soldier. While other occupations have been well studied and are readily understood the culture of soldiering, is often only understood by those who are in the military.

The demands of killing, avoiding being killed, caring for the wounded, and witnessing death and injury are all part of military service. Additional military

Summary of Findings

The literature reviewed for this study supported the importance of understanding the unique needs of veterans as they transition to long-term care settings, (Alder &

Castro, 2013; Katz, 2012; Settersen, 2005). It highlighted the work of Hersch et al.,

(2012), who developed an intervention that facilitates older adult adaptation to long-term care, and the work of other researchers who have found common themes facilitating improved quality of life of older adults who reside in long-term care (Brandburg, 2007;

Brooker, Woolley & Lee, 2007; Guse & Masesar, 1999; Sorrell & Durham, 2011;

McKenna, Broome, & Liddle, 2007; Moore, Delaney & Dixon, 2007). The concept of adaptation was defined through the literature. The definition was grounded in its relationship of older adults transitioning to long-term care (Frank, 1996; Hersch et al.,

2012; Lawton & Nahamow, 1973; Schultz & Schkade, 1997; Yerxa, 1967). The literature examined adaptation as it relates specifically to the transition of veterans to

LTC, (Adler & Castro, 2013). Lastly, military culture was discussed as being a viable component of cultural heritage for veterans, (Adler & Castro, 2013).

Although occupational therapy literature related to the adaptation of non-military- related older adults in LTC settings was readily available, as is research supporting the effectiveness of occupational therapy interventions in promoting well-being of older adults, occupational therapy literature addressing veteran adaptation to long-term care was non-existent. The profession of occupational therapy has the potential to significantly impact the quality of care for aging veterans through increasing understanding of military culture and cultural heritage of veterans who are transitioning to LTC. This study has the potential to increase the understanding of individual cultural heritage and military culture in general amongst caregivers of veterans transitioning to long-term care and provides an intervention to facilitate improved adaptation to long-term care.

CHAPTER III

STUDY ONE

Statement of the Problem

Currently, 43% of male veterans are over the age of 60, (Katz, 2012). In addition,

1.8 million soldiers have deployed in combat operations in Iraq and Afghanistan since

Sorrell and Durham, (2011), state the Veteran Affair’s Medical Center’s long- term care facilities cannot meet overwhelming current demands and provide support for veterans with cognitive and physical deficits, who can no longer be cared for at home.

They note it is imperative that immediate measures be taken to strengthen resources for research, manpower, and training to accommodate the relocation of aging veterans from home to long-term care.

Department of Veterans Affairs, 2012). Nevertheless, 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 a long-term care setting does not exist.

Statement of the Purpose

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. The research question for this part of the study was as follows: What person and environment factors emerge when veterans offer their perspectives about adaptation to long-term care?

Hersch et al., (2012) defined adaptation as a normal process in which a person encounters a perceived challenge in the environment and successfully manages that challenge. This dissertation captured the unique cultural needs that exist specifically amongst aging veterans. When staff members obtain a better understanding and appreciation for a specific veteran’s cultural heritage and military experience, a facilitative relationship develops that supports adaptation of the veteran to LTC.

This chapter provides the qualitative results from participant interviews. It includes the following: a description of participant demographics; the qualitative interview findings; and participant quotations supporting person and environment factors of veterans who have recently transitioned to long-term care.

Definition of Terms

Military culture, for the purposes of this study, was defined as the manner in which military experiences shape an individual’s worldview, (Kirchen, 2013). Military experiences influence the perspective of both the service member and his or her

immediate and extended family. For example, on average, a military family relocates every two to three years, (Adler & Castro, 2013). They may live overseas and seldom live near extended family members, (Adler & Castro). Therefore, the worldview of a military family may be quite different than that of family who has lived in one geographical location for many generations.

Occupation-based is defined as using meaningful and purposeful activities in the participant’s natural environment as a therapeutic means supported by the belief that human engagement in meaningful, purposeful activities is essential to health and wellbeing, (Reilly, 1962). Hersch et al., (2012), defined cultural heritage as the learned beliefs, customs, actions, communication and life ways of a person. A veteran’s cultural heritage may be influenced by childhood traditions, religious beliefs or other life experiences that shape the unique person who he or she has become. Military culture and cultural heritage can be distinguished for the purposes of this study by associating person factors that relate to military experience as military culture and those that do not as cultural heritage.

Researcher’s Perspective

and mother for the past sixteen years. In addition, I am currently the rehabilitation director for a state-funded veteran’s home in southeastern United States. I have experienced the benefits and challenges of military culture from multiple perspectives across the lifespan. I believe that experience gives me special understanding of these veterans and the issues they face as they relocate to long-term care facilities.

Background and Significance

Katz, (2012), emphasizes that veterans are distinguished by their history of service to their country, their training, and their membership in the unique culture shared by those in the profession of military service. Due to combat exposure, veterans experience service-related mental and physical suffering and disability that differs from the civilian population. The disabilities experienced by veterans, coupled with the aging process, affect veterans in different ways at different periods in their lives. Katz contends that because veterans are part of a unique culture, the aging process for veterans must be studied and understood in a distinct manner from the civilian aging population.

Settersen, (2005), states that detailed data on military experiences are needed for research policy and practice. He also emphasizes the importance of understanding the

impact of military service on later life as millions of veterans worldwide move through advanced old age and younger veteran populations move into old age. The profession of occupational therapy has the potential to significantly improve the quality of care for aging veterans through research and practice. Nevertheless, occupational therapy literature focusing on veteran adaptation to long-term care settings is currently non- existent. Similarly, there are limited qualitative studies examining the perspectives of veterans as they age. As such, the world-view of veterans transitioning to long-term care is not well understood.

Social isolation, environmental deprivation, and a lack of meaningful occupation can intensify depression and other disabilities in older adults, (McKenna, Broome, &

Liddle, 2007). The transition and adaptation of older adults to LTC settings often disrupt one’s daily routine and access to meaningful occupations and can lead to increased depression and decreased quality of life, (Hersch et al., 2012). Guse and Masesar, (1999), explored factors related to quality of life and successful aging in LTC from the perspective of residents. This qualitative study revealed two themes as being important to quality of life for older adults who resided in LTC: enjoying nature and being helpful to others. McKenna, Broome and Liddle, (2007), examined time use in relation to role participation and life satisfaction in older adults aged 65 and older. The study was conducted within the community setting. It suggested older adults’ occupations and roles are diverse and age does not reduce occupational or role engagement. The study

concluded that facilitating participation in valued roles was important to an older adult’s quality of life.

Literature suggests that “being understood” and “feeling connected” to a facility is a key aspect of adaptation for older adults in LTC settings, (Brooker, Woolley & Lee, 2007;

Brandburg, 2007; Guse and Masesar, 1999; Moore, Delaney & Dixon, 2007; & Sorrell &

Durham, 2011). Therefore, research is needed to better understand the specific needs of veterans who transition to LTC facilities.

Hutchinson et al., (2011), used a phenomenological, qualitative approach with a multiethnic, multidisciplinary team composed of nursing and occupational therapy faculty and graduate students to investigate person and environment factors of elders that facilitated adaptation to long-term care facilities. The findings revealed the following themes; spirituality, death, dying and philosophy of life, life experiences with change, cultural heritage, health, ethnicity, social support, LTC facility relationships, LTC facility maintenance and LTC support of personal growth. The study suggested by implementing the Occupation-based Cultural Heritage Intervention (OBCHI) during the relocation period, the cultural heritage of each individual in the group would be highlighted to promote the person’s adaptation to the facility.

Relocating from one’s home to long-term care involves adaptation because it includes leaving behind family, friends, routines, community groups, pets etc. The concept of adaptation has been used in occupational therapy research and practice as a means and an end when providing authentic occupational therapy, (Frank, 1996; Schultz

& Schkade, 1997; Yerxa, 1967). Adaptation can be defined as a person’s relationship with his or her environmental context, (Lawton & Nahamow, 1973). Adaptation for the purposes of this study was defined as the process by which a veteran encounters a perceived challenge in his environment and successfully manages that challenge as measured by increased quality of life, activity engagement and social participation,

(Hersch et al., 2012).

(Bol, & MacMaster, 2003; Chao et al., 2008; Hersch et al., 2004). However, research that examines factors facilitating veteran-specific adaptation to LTC settings is not readily available but it’s likely that these same indicators for older adults may be applied to an aging veteran population.

When one relocates from one setting to another setting, he or she attempts to assimilate his or her cultural practices and beliefs into the new setting. Hersch et al.,

(2012), propose that the more successful the resident is with incorporating his or her cultural heritage into the long-term care environment, the higher the quality of life,

activity engagement and social participation will be for that particular individual.

Military culture, as well as other cultural elements, is an important aspect of cultural heritage that must be better understood and incorporated into treatment in order to facilitate successful adaptation of veterans to long-term care settings.

Adler and Castro, (2013), U.S. Army psychologists, developed a model entitled the Occupational Mental Health Model (OMHM), a modification of the Soldier

The demands of killing, avoiding being killed, caring for the wounded, and witnessing death and injury are all part of military service. Additional military occupational demands include frequent relocation, separation from family, and twenty- four/seven availability. While other occupations may have similar demands, the demands identified here are salient features of military service, (Adler & Castro, 2013). Civilian health-care providers, who treat veterans, whether it is in a military setting or civilian sector, rarely understand military culture, (Adler & Castro).

Methods

This study used a qualitative phenomenological approach to explore the person and environmental factors related to successful veteran transition and relocation to long- term care (LTC) settings. This approach was selected because it best explores how aging veterans perceive their experience and transforms those perceptions into reality, (Patton,

2001). Narratives were explored to extrapolate meaning and to organize participant daily actions and events into common themes, (Hasselkus and Murray, 2007). The phenomenon examined in this study was adaptation in relation to culture, heritage, occupation, and specifically, military culture. As such, participant statements relating to the above-mentioned topics were annotated and studied.

Institutional Review Board (IRB) approval was obtained from the university and the facility where the intervention took place prior to the initiation of participant recruitment. All participants gave informed consent prior to participation in the study and pseudonyms were used for actual names to maintain confidentiality.

The sample consisted of 10 male, long-term care residents who were admitted to a state veteran’s home in North Carolina within approximately

of the interview. The participants were between the ages of 60 and 92 years of age with a mean age of 82.27 years and scored a five or better on the Short Portable

Mental Status Questionnaire (SPMSQ) (Pfeiffer, 1975), prior to selection. The mean participant score for the SPMSQ was 95.45%. Nine of the eleven participants scored ten correct out of ten possible on the SMPSQ. See Table 1 for Demographics of the Sample.

Table 1a

Participant Demographics Table

Participa Age Ethnicity Military Combat Primary nt Branch/ Experience Medical Years of Diagnosis Service 1 88 Caucasian Air Force- WW II TBI 20 2 92 Caucasian Army-4 WW II Cancer 3 87 Caucasian Army-4 WW II Debility 4 60 African- Air Force-8 No Combat MS American Experience 5 90 Caucasian Army-4 WW II Leukemia 6 88 African- Army-30 Korean/ CVA American Vietnam 7 68 African- Air Force-4 No Combat CVA American Experience 8 64 Caucasian Army-20 Vietnam CVA 9 78 Caucasian Army/Navy Vietnam CVA -22 10 92 Caucasian Airforce-4 Korean War Debility

Note: All participants were male, scored within a functional range on the SMPSQ (five or >) and were taking a consistent (same dose/medication for over six weeks) dosage of medication to manage depression. Frequent is defined as at least 1 visit or outing per week.

Tools

The Short Portable Mental Status Questionnaire, (SPMSQ), (Pfeiffer, 1975), was administered as a pre-screening tool. The SPMSQ has been found to be a valid and reliable cognitive screening tool, (Roccaforte, Burke, Bayer & Wengel, 1994).

Participants continued with the study if they scored five or better on the SPMSQ. The

Life Narrative Interview, (Gubrium, 1975/1997), combined with the Cultural Heritage

Interview Guide, (Hersch, 2013), was used to collect data for this portion of the study, as was the Military Culture and Lifestyle Interview, (Kirchen, 2013). Rationale and psychometrics of the tools are derived from Gubrium's extensive research and the work of Hersch et al., (2012). See Appendixes A-H for forms and guides.

The researcher used field notes to document salient participant comments, emotions, questions, concerns and body language. The field notes included the date of the interaction/observation, location, who was present, social interactions and activities took place, (Patton, 2002).

Data Collection

The data collection took place over a four-week timeframe. The primary researcher supervised three trained graduate students and five, trained research assistants who administered the SPMSQ, (Pfeiffer, 1975) and conducted the interviews. The interviews were recorded via audiotape and transcribed verbatim for accuracy purposes.

The three master’s-level students conducted interviews of participants using the

Life Narrative, (Gubrium, 1975/1997), Cultural Heritage Interview Guide, (Hersch,

2012), and the Military Culture and Lifestyle Interview, (Kirchen, 2013). The interviews were conducted in a distraction-free setting, at the convenience of the participant. The interviews consisted of one session, or multiple sessions, depending upon the fatigue level of the participant. The average length of a participant interview was ninety minutes.

The interviewers were trained on consistency of interview methods and approach prior to the initiation of this study.

Data Analysis

Qualitative interviews were audiotaped and transcribed verbatim by three trained research assistants and a professional transcription company. The primary researcher and two graduate students attempted to eliminate bias from the qualitative phase of this study by reaching epoche, (Patton, 2002). Epoche is an analytical process, in which the researcher attempts to suspend judgment of the data or outcomes until sufficient evidence is in, (Patton). The second step in the analysis of the qualitative data is phenomenological reduction. In this process, the researcher “brackets out” extraneous data to leave the remaining data in the pure form. Bracketing includes the following steps:

1. Locate the key phases that speak to the phenomenon of culture, context, time use

environment and social participation. For example, Participant Six stated:

Umm…I got one thing that bother me more than anything else and that’s (people that haven’t been in the military don’t know how to work the veterans) and uhh now (that’s something that bothers me greatly but for whatever reason the management allows it).

2. Interpret the meanings of these phrases. The first above-mentioned phase speaks

to the phenomenon of military culture and was coded as such. The peer reviewers

interpreted the phrase as meaning participant six would prefer LTC staff members

had an understanding of military culture. The reviewers interpreted the second

phrase as meaning that the patient feels he has little or no control over the staff

who are hired and it was coded as such.

3. Obtain the subject’s interpretation. Member checking was conducted, i.e. the peer

reviewers clarified with participant six he meant understanding of military culture

is important for staff members who work with veterans. In addition, the

researcher verified Participant Six felt as if he had a lack of control over the

quality of staff hired by the administration. The researcher conducting the

member checking asked, “When you said…., did you mean…?”

4. Inspect these meanings and identify recurring features of the phenomenon in the

data. All data clusters with a similar themes/meanings were grouped.

5. Define the phenomenon in terms of reoccurring features.

After the data is bracketed, it is “horizontalized” or spread out for examination. All data has equal weight and is organized into meaningful clusters. The clusters are organized into overarching themes. A panel of 2 to 3 peer reviewers, well versed in qualitative research, reviewed the transcripts and followed the above-mentioned process

(Patton, 2002). The peer reviewers consisted of a psychology graduate student who had conducted three qualitative studies, an experienced occupational therapist and an occupational therapy graduate student, who had both participated in at least two qualitative studies and completed qualitative research coursework within the past year.

The psychology graduate student and the occupational therapist had limited access to the data and the findings, however the occupational therapy graduate student had full access to data and findings. The peer reviewers met to discuss key phrases and reviewer interpretations; consensus on overarching themes was agreed upon. In the above-

mentioned example, participant six was the only participant who specifically verbalized the importance of staff members having an understanding of veterans. Therefore, this theme did not become one of the overarching or secondary themes of the study. However, the theme LOC (Lack of Control) occurred 29 times throughout participant interviews and it was identified as a secondary theme under the overarching theme of Home.

Trustworthiness Techniques

To assure credibility of the study, member checking was conducted with all ten participants for areas of the transcripts that were not clearly understood by the primary researcher. The primary researcher clarified and revised the participant’s statement until the participant was in full agreement that the statement was accurate and complete. The primary researcher and three peer reviewers agreed on data codes, clusters and themes, which supported finding credibility and dependability. The primary researcher maintained a field journal to assist with description and reflection of experiences. The researchers also provided an audit trail of transcribed audiotapes, questionnaires, and the field journal. Confidentiality of data was ensured. The research assistants received patient confidentiality and HIPPA training, which included passing an exam, prior to the initiation of the study. All assessment tools, audiotapes were returned to the primary researcher within three hours of being completed and secured in a locked file cabinet in the primary researcher’s office.

Findings

Data analysis of transcribed interviews revealed person and environment factors as depicted by their quotations, which are detailed in Table 2. Both person and environment factors included several themes and are described in the following text.

Person Factors

Person factors are factors that affect the health and wellbeing of the person

(Kirchen, 2013). External person factors include: family and friends. Internal person factors include: spirituality, cultural heritage, etc.

Family. Participants emphasized family (see Person Factor A, Table 2) throughout the interview process. They described childhood experiences, traditions and relationships with family members. Participants also discussed family in the context of their military experience, i.e. wives waiting for husbands or parents worrying about the safety of soldiers/children. Family continued to be an important cultural theme throughout the lifespan of the participants. All ten interviewed participants discussed their family in the present context. One participant stated: “It’s when your children grow up to be healthy and happy that you know you have really achieved something,”

(Participant 2).

Spirituality. Spirituality (see Person Factor B, Table 2) was strongly emphasized in eight of ten participant interviews. Participants described teaching Bible classes, becoming an ordained deacon and attending church as a child and adult. Interestingly, eight of the ten participants stated they did not regularly attend church while they were in

the military. The military offered services, but service members often worked on

Sundays or were in wartime situations not conducive to attending services. However, one participant stated: “You won’t find an atheist in a foxhole. We might not have been able to go to church, but we were sure praying” (Participant 9).

Military role. In nearly all aspects of the interviews, participants discussed their role in the military (see Person Factor C, Table 2). They described the places they had been and the specific job they held. The varying number of years in service did not affect the participant’s ability to recall the details of the positions he held while serving his country. All eleven participants reported having had both positive and negative experiences while in the military, but each of the participants stated if he had to do it all over again, he would, without a doubt, choose once again to serve his country.

Cultural heritage: food, music, and celebrations. When participants were asked about their cultural heritage, they most often discussed childhood traditions (see

Person Factor D, Table 2). Christmas was mentioned most often and described as combining food, family and music. During military deployments, participants reported not being unaware of holidays. One Participant stated: “Christmas and Thanksgiving were just another day. We had a job to do and we did it,” (Participant 9).

Food was discussed in seven of ten interviews. Participants most often discussed food as it related to childhood memories, such as one participant who had a German mother who cooked schnitzel. He reminisced: “My mother used to make me the most wonderful schnitzel. I haven’t had it in years, and I sure do miss it,” (Participant 8).

Another participant, raised by his grandmother, described eating barbeque pig’s feet every Sunday. The participants described food as having a strong connection to family and home.

Six participants commented on the importance of music either in their past or present lives. One participant sang in the church choir. Another participant listened to

Big Band music in his room every afternoon. Music was also strongly associated with holidays and celebrations. One participant sang military cadence during his interview.

Military cadence is used to facilitate marching maneuvers or during exercise when soldiers run in formation.

Life, according to the participants, seemed full of celebrations, babies being born, birthdays celebrated, children graduating from high school. Yet, eight of ten participants reported not enjoying holidays and celebratory events since being admitted to long-term care. One participant stated: “I hate the holidays. They aren’t what they were then and they can’t be like they were, here,” (Participant 2).

Environment Factors

Environment factors are factors within the physical setting that affect the health or wellbeing of a person (Kirchen, 2013). External factors include the structure of the building, access to outdoors, etc. Internal environmental factors include policies that guide patient care and/or building management.

Home. Participants were consistent in their feelings that the facility was not like home (see Environment Factor A, Table 2). They recognized their needs were met, but they did not relate that to being at home. Participants mentioned lack of privacy and comfort in the facility as being different from home. Participants were not directly asked about their particular LTC setting or staff. However, when asked whether the facility felt like home, several themes emerged.

Having control/making choices. A frequently expressed concern was regarding participant lack of control and/or opportunity to make choices (see Environment Factor

A, Table 2) within the facility setting. One participant described not being given bathroom privacy when he requested it. Another participant stated that the residents’ lives are set around the staff’s schedule rather than what the residents wanted or needed.

All participants indicated they would like to have more control over their lives and want to be offered more choices, especially related to food or activities.

Social participation. A sense of loneliness and isolation is a strong theme that emerged from the data. Participants described not being able to socialize (see

Environment Factor A, Table 2) with other residents. One participant stated that he

attempted to communicate with several residents, but, “They weren’t all there,”

(Participant 2). Six of the ten participants have roommates who are nonverbal and require complete care. Participants recognized the importance of socializing, but were challenged to find fellow residents who were able to converse on their level.

Another barrier to social participation was the age difference between some participants. One participant noted: “I don’t have anything to talk about with other patients. I am twenty to thirty years younger than most of them. What would we have in common?” (Participant 8)

Leisure. All but one participant discussed leisure activities (see Environment

Factor B, Table 2) in the past tense. They described activities engaged in while in the military or civilian sector. Participants tended to describe leisure-time activities as something that was done with families over the weekend or while on vacation.

All of the participants related physical dysfunction with an inability to participate in leisure activities of choice. One person voiced his frustration with not being able to use his right arm due to a stroke. He said: “One minute I was fine. The next minute I was lying on the floor and my world changed forever. I couldn’t fish or play softball. You just want to quit life when you can’t do anything anymore,” (Participant 8).

In contrast, seven of eleven residents reported engaging in leisure activities. One participant mentioned playing Scrabble on the computer. Another person described performing gardening activities in the facility outdoor area. Several of the participants enjoy listening to music or playing Bingo. Two participants read books via e-readers.

Notably, the residents who reported engaging in leisure activities within the facility did so in isolation. The social participation aspect of leisure activities rarely occurs per participant report and primary researcher observation.

Military culture. Military culture permeated the interviews and was the common bond amongst all residents within the long-term care setting. One participant captured the sense of camaraderie that exists in the military. He said:

I retired from the Army. All the retired men stopped on going to combat but I'm still a soldier in the army. As far as I am concerned, and I'll fight and argue over it because the army was my life and I still live it that way, enjoy it and uh, and most of the people here are soldiers, marines, sailors and we all tease a little and get along but we get along but you know, spend time looking after each other. And this is the life that makes it worth it. I don’t take credit for nothing but there’s several guys who I talked to here now, I got them smiling and talking back, appreciate people, and uh getting along, makes me feel that maybe this is what I was meant to do. If I can’t do much rolling around their wheelchair, at least I can speak to people, and cheer them on and get them smiling and working more, because that’s the first thing you have to learn (Participant 9).

Another participant expressed his concern about staff members’ lack of understanding of military culture.

Umm…I got one thing that bother me more than anything else and that’s people that haven’t been in the military don’t know how to work the veterans and uhh now, that’s something that bothers me greatly but whatever reason the management allows. You see these guys…these black guys with the long dreads working here, you see that and they got one or two at work with the resident and that bothers me with a passion seeing men with the long dreads and you can’t see anything good or admiring…I don’t know why in the world, you know, where that started and uhh ghetto…ghetto…ghetto. You know what ghetto is? Them kinds of people…you see them on the streets right now with them long dreads. I hate it. Why do they do that? We didn’t do it like that; you know naturally we had to stay clean, shaved and everything. I…I just…I don’t (understand) (Participant 6).

Table 2

Person and Environment Factors

Person Factor A: Family

Question: Who was important to you in your life?

My father. He was the most important. (Long pause) he was much older than me at the time. He was semi-retired. He was working on and off for the company I worked for at the time, and he taught me an awful lot…in meeting strangers, how to get along with them, talk to them. He was an important person in my life, nothing in return, it just happened that way. We traveled a lot together, and it was during this travel that we did a lot of talking. And he wasn’t…uh he wasn't uh easy, if I was doing something that wasn’t right he told me. I might have been addressing a crowd and afterwards he say uh at this point you should have said this instead of what you did say (Participant 5).

Can I put my wife down as a highlight? She’s the most wonderful; she’s the best in the world. Ooh, we’ve been married 62 years (Participant 10).

Question: What were the highlights in your life?

The best time in my life (pause) was probably two times: coming out of the Army in one piece because I saw quite a bit of action. And I came out in one piece. I was happy about that because my wife and I were married when I was in the Army. She insisted on it. I wanted to wait until after the war was over, but she wanted to get married. And we were married and 2 days afterwards I left for overseas and didn’t come back for nearly 4 years... the ones that were in the military, learned that…when they come back…come home…we learned to live with our wives our husbands and it isn’t living as we did in the military (Participant 5).

Question: Tell me about your family.

My son’s here, we go out, my granddaughter comes to see me a good bit, my great grandchildren come, my great grandson starts college this fall, my great granddaughter should be a sophomore in high school this fall (Participant 2).

I says, ‘and every day, tell your kids you love them.’ I says, ‘don’t say ‘well they know that.’’ I says, ‘tell them.’ I says, ‘never think they don’t’. I says, ‘then spend time.’ I says, even if it’s 5 minutes, with them. Individually. One on one.’ I says, ‘let them know that they’re important to you and they’re special.’ I says, ‘give them time of their own to really, you know, to know it and understand it (Participant 9). 36

Person Factor B: Spirituality

Question: Tell me about your spirituality.

Well they make me feel better you know you go to church. You know how it makes you feel different and then you go see a play or something takes your mind off your other troubles for a while and uhh I think that’s about it as far as I know (Participant 1)

…As I said helping people and it was recognized in the church…the church I belonged to but because of what I did and the work I did with children not so much as…might be the work I did in the army to make it look nice but it’s the work I did with the children that I was called up and ordained in the Presbyterian church as an ordained elder (Participant 5).

I love everybody, I like to see everybody succeed you know, but if they don't want to, I try not to worry about it you know, and I, thank the Lord for my family, that He is taking care of them and everything. I just, you know. That's just who I am (Participant 6).

I’m a very religious guy, don’t matter what color you are I got to treat you with respect, that’s what I told my young daughters (Participant 7).

I don’t consider myself to be a strongly religious man of such. I believe in the Lord, I go to church at times and I always prayed. They always said and I heard there is no atheist in a foxhole. Well, when the first round comes in, you hear more people praying than you ever know about. Now, my son married a Muslim girl. And when I was in Jakarta, Indonesia with her family, some of her family got up to me and asked me how I felt about a Christian marrying a Muslim girl. And I looked them straight in the eye and told them that all the years that I spent in Korea and in Japan and the different countries, I found out they all believe there is one God and only one God. I said, there is only one God. Who is to say who is right on how will you honor that God? I said we all honor Him in our own ways, I said, which one is right, which one is wrong. From then on, they thought of I was a member of their family, (Participant 9).

Person Factor C: Military Occupation

Question: What did you do in the military?

I remember too much sometimes. I was a bombardier at the air force I hate to think of all the people I killed, I didn’t mind killing them there people who would shoot at me. We did some of that, but when you bomb say a railway or something like that. You know you gonna blow up a lot of houses not all of your bombs are gonna land on one place, you got to think of women and children and people like that but they would do it to us at the same time I 37

remember being London and be bombing and then they were hard times all the way around. I never got to know people. We’d get a crew moving anyone many who lived took crews to a hut and they wouldn’t be there long enough and would get shot down and then another crew would come in and they wouldn’t even be able to do anything and they’d be shot down fortunately we didn’t get shot down. We came close to it a few times (Participant 2).

I was a gunner’s mate third class. Well, they...uhh, they...uhh [long pause, heavy breathing]. The armament, uhh, on..On the ship, consist of guns and that’s the gunner’s mate job is to take care of them and they usually maintain the guns and during wartime they uhh...uhh...uhh kinda like direct the...the firing and all that yeah...yeah (Participant 3).

Ordinance section. That was the section I was in and what we did was we put the bombs in the airplane. We would make an area of safety or bombs and ammunition and we loaded the planes with the bombs. We would bring out the cases of ammunition, give it to armament so they could load the guns in the plane that was...now as we loaded the bombs into the plane, we had to put fins on them. We used to. We had to put the fuses. There was a fuse in the front and the back of the bomb and then we’d put in what was called an armament wire which were we…uhh lifted the bomb off into the plane and hooked it into the rack. We took quite a bit of action during the war and we were…we became very good at what we did. And this is what we were noted for and what our bronze plaques in the air corps academy in Wright- Patterson noting the fighting ability at both ground crew and infantry as needed. (Participant 5).

Well, I, uh, I was in Vietnam, and I was in Korea, those, those were pretty, pretty rough times but yet and still, I wasn't by myself you know. A lot of times we didn't have anything to eat we ate cook out meals…But I had an experience with it, I was on patrol and I came to the village and the women was crying, don't hurt my baby, and keep saying, don't hurt my baby, don't hurt my baby. So, my crew, I didn't like that and oh fine you know what I'm saying. And uh, they stood there for a while I said well, I said, let's go. I said, we're not going to bother them, and said don't hurt my baby, and I said, Ma'am, we're not going to hurt you, we're not going to bother you. So we went on, we didn't bother the children, we didn't bother the lady there (Participant 6).

Well, my wife didn’t get used to it. She wanted to do a lot of travelling. At that time working as a security policeman it’s like tiresome, dealing with nuclear weapons every year we had to go to the psychiatrist because that work could be stressful. And it won’t know what your thoughts were. You know like they have a lot of guys wanting to commit suicide there like right now all the guys’ fatigue it affects your brain, your nerves and stuff like that. Yea so…(Participant 7).

When I was in at the army, I became in-charge of certain men. These were men of my responsibility to take charge of. And every time I put a stripe on, it was more men and bigger 38

responsibility. And for the eighteen years, I took care of my men and did the best I could and to this day, everybody laughs at me. I said, well, I retired from the army so every month they would send me a paycheck. I figured I’m still in the army. I still got men to look after and help. And we try to, and we, everybody in the room, and it makes it, you know, all of us feel a whole lot better. I think (Participant 9). Person Factor D: Food, Music, Celebrations

Question: How did music, food or celebrations influence your life?

Yeah we always had uhh music going and uhh like Christmas time, if it was Christmas time it would be Christmas music. And we always celebrated “Family Come Home”, Thanksgiving, July the fourth and all those all them are important. We’d have them all together they all come and eat at mama’s (Participant 1).

I hate the holidays. They’re not like they were then and they can’t be like they were here. And um, I went to my granddaughter’s a lot for the holidays and till I ended up in the hospital. They wanted me last Christmas, but I was even weaker then, than now so I didn’t try, but I might try this Christmas if they ask me again (Participant 2). Oh yeah, yeah, I grew up with the, I grew up in the 40s with the big bands and the..everything…I still love it, oh yeah (Participant 3).

You gotta have a plan to get outta here. If you don’t have a plan you lost. When my daughter said she was getting married my plan was to walk down the aisle no matter what. This is preparing me to do that, with walking without guidance or whatever. If you sit down and pity yourself and feel sorry for yourself you not gonna do anything (Participant 7).

My mother was German. So it wasn’t holidays. It was just lifestyle. We ate German food. I miss eating schnitzel. They don’t serve any German food here. I love to eat fresh, fried catfish. We don’t get that here either (Participant 8).

I love anything just about. I don't eat onions and bell pepper. Uh, some of the onions, if it's cooked right, the food I eat, my wife says, she's allowed, she cooked. But I love her coleslaw, her meatloaf and her potato salad. But I was raised on Mexican food (Participant 9).

And I told my son when he got married, I says, ‘there’s 4 things to try and remember’ I says, ‘the first,’ I says, ‘is extremely important.’ I says, ‘remember your wife’s birthday.’ I says, ‘if you don’t hell will come.’ I says, ‘remember your wedding day.’ I says, ‘those two remember.’ I says more than anything else. I says, anything else, Christmas, Valentine ’s Day (Participant 9).

Yes I do Iike, uh, I like church music. I used to sing in the choir when I was able to attend the choir. I’m a tenor. Sometimes I wonder if during a church service, if I’m out there singing in the congregation, and someone tells me. Well, I heard your voice out there, I didn’t really mean for them to hear my voice out of the congregation (Participant 10).

Environment Factor A: Home Sub-factors: Control/Choices and Social Participation

Question: How connected were you with home when you were deployed?

Uhh…while you’re in the military you still don’t lose contact with home. We tried to do what we could in the military to make the people at home uhh…as free as they could from worry…because to find out from your…your parents have been in the military, served in wartime and so forth and then came home, they realized how that…all the time you’ve been away from home, they worry. They continue to worry about you (Participant 5).

Question: Does this facility feel like home to you-why or why not?

Well I guess as comfortable as you could be if you gotta be in someplace, but I’d be more comfortable living at home. I stayed at home until I was 91 and I could drive and ride up, until I ended up in the hospital, like what happened at fell and when I’m about to get up in the morning my feet just wouldn’t hold me. I couldn’t get up so I dialed 911… I mean as good as it could be, sure I’d like to be at home, I’d like to, if I had a lot of money (Participant 2).

We have a room, we have all the basic necessities for life here. Uh, I’m fortunate enough to be able to have a computer and know how to use it. I don’t know if there’s anything else that they can really do to make us feel more comfortable. There’s not much more they can do. There’s no place for a recliner in here or a sofa. You know what I mean? Or the nice king size bed that I had before my stroke. (Participant 8).

I guess I have as much control as someone in my situation can have. I’d like to have more control, but because I can’t. They’ve all been real good to me. But my roommate is not with us anymore, he wakes me up a lot at night, but he can’t help it (Participant 2).

Life here takes away your respect. I used to be able to do for myself before I came here. But in my case I can’t do it anymore and somebody has to do it for me. You can’t be free. You have very little control. I had to switch (caregivers) because I asked the person to respect my privacy and she wouldn’t do so. I was on the toilet and she wouldn’t shut the door. The staff just comes in and does what ever they want to do. They don’t tell you first or even talk to you at times (Participant 4). 40

If you're not too popular, they don't treat you too good, no. There's a classic example, that's the way, my bed and me, uh, my bed is supposed to be straightened out and everything. Look at it. My room and the bed, you see how messy it is? (Participant 6),

I obviously have a roommate here, which I didn’t when I was living by myself with my dogs. Yeah, little Chihuahuas. And uh I had the independence of going out and getting in my car and going out and get something to eat where there’s not a lot of choices here. So there’s some big differences. I can control what I wear. I can control pretty much my time, what I want to do, my time management. Uh, if they played bingo and I don’t want to play bingo, I can do something else. (Participant 8).

I wish there were more choices, privacy and respect here. I would like better food here like hotdogs and simple things that I miss. Everything is by schedule (Participant 4). Most of people that I met here, their minds, they can’t really have too much activity with them. I try sometimes, and I talk to some of the gentleman that I seen over in the exercise place that was in the 8th Air Force and I tried to talk with him a couple of times, but he’s not all together with it (Participant 2).

Well, I was more comfortable when I lived with my brother, but I did not want to be a burden. The people here don’t care about me as a person. In other words, the job is more important than the people. I don’t talk to any of the residents. Every person, I hate to say is 20 to 30 years older than I am (Participant 4).

Environment Factor B: Leisure

Question: What did you do in the past or do you do now for leisure?

I could read and I…I watch television, I have courses I take and… I’m curious about things, like one that I’ve got there now is that taught me protocols like I don’t understand at all, but I enjoy trying to understand it. I’ve got another one over there, Einstein and quantum and one on the universe, among different things. At home I’ve got some on art and history. Different things (Participant 2).

I love to fish. Me and the wife used to go bass- or catfish fishing out here in this part of the country (Participant 8).

They have different socials. What they call the socials, they have a hotdog social, they have a French fries social, they have an ice cream. And then, maybe I shouldn't say it, but they honor us immensely here. Every couple of weeks, they will take a group, whatever, you have the best, the ones that can operate a little or talk or work other than the bedridden patients. They take them to a seafood restaurant or to another restaurant, to steak house for dinner. 41

Organizations come down (to entertain) at different times, but I don’t usually do any of that (Participant 9).

They got four, four by eight pitch, out back for the dirt, they have full of dirt that somebody on a wheelchair can work at and plant plants, and flowers and everything. We’ve been growing tomatoes, zucchinis, uh, eggplant, bell peppers, hot peppers, and everything in our garden but we have flowers in there, too. And just to go outside, and what we do we try to get out everyday, we got to go out weed the garden, and a lot of the, uh, I get in trouble because say the inmates because we wander in one of those doors with the rock you know, but uh, the residents go out and we work in our garden and we get to grow, we grow the tomatoes and everything else and we get to cook them. And eat the food that we’ve grown, and eat it, it makes it great, gives you something to look forward to. It’s better than just laying here in a bed staring at four walls-just getting outside, seeing the plants, the color of the plants makes you feel better (Participant 9).

Discussion

The phenomenological analysis of the qualitative interviews provided insight into

the lived experiences of ten aging veterans who reside in a long-term care setting. Results

indicated that residents enjoyed thinking about and retelling these familiar person and

environment experiences that have met their social, emotional and physical needs in the

past and. Such reminiscence experiences, very well, could continue to be of benefit in

future interactions and activities in the facility and be used in planning culturally based

activities to enhance veteran adaptation to long-term care settings.

Implications for Long-term Care Facilities

Participants expressed a need to be able to interact with other residents who are

cognitively intact. Out of 150 residents who reside in the facility, approximately 15

residents present with intact cognition. Many of those residents are not housed on the

same wing and do not have the opportunity to interact with other veterans of the same

cognitive abilities. To support the importance of social participation, Gilmour, (2012), conducted a study examining the correlation between social participation and health and wellbeing. She used a multivariate logistic regression research design to examine 16,369 people aged 65 or older. An estimated 80% of participants reported being engaged is at least one social activity per week. As the number of different types and the frequency of social activities increased, so did the strength of associations between social participation and self-perceived good health. Similarly, there was a correlation between loneliness and life dissatisfaction. The desire to be involved in more social activities was reported by

21% of senior men and 27% percent of senior women. This study supports the correlation between social participation and self-perceived good health. Nine of ten participants in this study reported feeling socially isolated, which based on Gilmour’s findings, can lead to life dissatisfaction.

Choices and control. Despite physical impairment, the participants in this study expressed a desire to have some sense of control over their lives and routines. They would like the opportunity to make choices, especially about food and activities. Schnelle et al., (2013), conducted a controlled trial of an intervention to increase resident control in long-term care. The researchers recruited 169 long-term care residents and the certified nursing assistants (CNAs) who cared for those residents. The intervention consisted of

12 weeks of training, focused on educating CNAs how to incorporate choice into the resident’s morning care routine. The intervention post-test revealed a significant increase in the number of choices CNAs offered residents, however offering choices also required

more time. Schnelle et al., (2013), noted Federal guidelines for nursing homes now mandate resident-directed care, meaning residents must be offered choices in how their care is provided. The authors of the study found only a third of residents residing in nursing homes in the United States are allowed to determine their own daily schedule.

One of the limitations of the Schnelle et al., (2013), study is it did not assess participant quality of life indicators related to having been given more choices. However,

Ball et al., (2004), conducted a Grounded Theory study that examined the importance of independence and quality of life of fifty-five assisted living residents residing in seventeen facilities. The findings revealed residents equate having choices and control over daily routines with being independent. Additionally, having a sense of independence was strongly correlated with resident satisfaction and increased quality of life.

Recommendations for offering residents choice, control and social participatory activities, based on study findings. Activity department staff, social workers and facility chaplains could screen the cognitive status of newly admitted residents. Residents who are functioning at a higher cognitive level could be encouraged to meet for Bible study, a book club, or other equally, cognitively challenging activity.

Residents should be introduced to each other upon admission to the facility to ensure social relationships begin to form. It is not possible for residents to instinctively locate cognitively compatible peers. Staff needs to facilitate this interaction. In addition,

housing cognitively compatible patients on the same wing or in the same room would increase the likelihood that social interactions would occur.

It would seem that activity department staffs could be advised to survey newly admitted residents and incorporate specific food, music and activities into programming to meet specific needs of residents. Residents may benefit from being given opportunities to plan activities and to lead groups. Activities need to emphasize social participation, i.e. discussion and teamwork. Seating for activities could be in a small group formation to facilitate social participation, rather than all the seats facing forward.

Another recommendation is to allow the residents to be given a daily opportunity to spend time outside. Several activities could include an outdoor component. Both the research of Guse and Masesar, (1999), and the findings of this study support the importance of consistent access to the outside environment as being important to the

QOL of residents.

Having family-centered activities offered several times a month is a strategy that facilitates positive family-resident interaction and, in turn, enhances positive staff-family relationships. If a patient would like to participate in a planned activity, but requires adaptations or modifications due to a physical limitation, activity staff might consult therapy for assistance. Items such as a cardholder, reacher, or other adaptive equipment may facilitate resident participation.

All staff could be trained on the importance of offering choices, such as asking a patient which shirt he would like to wear or what dessert he would prefer. Training staff

to understand that the facility is the resident’s home and the resident has the right to privacy will promote choice for the resident. For example, all professional caregivers need to knock before entering a resident’s room and carefully explain what he or she is going to do, prior to doing it.

Military culture and clinical implications. Military culture is the bond that unites all veterans, (Adler & Castro, 2013). It is imperative that staff members/caregivers not only understand, but respect, military culture, (Adler & Castro). The men and women who have served our country will forever be connected by their sense of duty to their country and to each other, (Bliese & Castro, 2003). For example, a resident may not be motivated to attend therapy, but when he or she is invited by another veteran who requires assistance, the veteran will most likely go. Most veterans thrive on routine.

Punctuality is imperative to providing quality care. Veterans pride themselves on cleanliness and professionalism. Wrinkled uniforms and unattractive (at least to the residents) hairstyles can be quite upsetting to a veteran, as evidenced by some of the remarks noted in the participant interviews.

Conclusion

A call has been made for increased understanding of military culture to facilitate provision of environmentally enriched LTC settings that promote veteran engagement in meaningful occupation and social participation, (McKenna, Broome, & Liddle, 2007).

Ten veterans have spoken about their lived experiences from birth to present day. They have identified benefits and challenges associated with relocating to long-term care.

Based on the findings from this study, veterans who reside in LTC settings have an ongoing desire to revisit military experiences with other veterans; however, five of ten participants stated it was a challenge to locate other veterans within the facility who could converse on their level. All ten participants stated they have little or no control over their routine from day to day and nine of ten participants indicated they would like to be offered more choices, especially with food and activities.

Veterans possess an innate desire to serve others, (Katz, 2012). The participants in this study voiced a need to feel useful to family, the facility and the community at large. They emphasized over arching themes of: home, family, spirituality, military occupation, leisure and food and music in relation to celebrations, as being important to them, both in the past and present. As thousands of veterans transition to long-term care centers across the United States every month, (Sorrell and Durham, 2011), healthcare providers must hear their voices and create long-term care programming that meets their social, emotional and physical needs.

CHAPTER IV

STUDY TWO

Statement of the Problem

Currently, 43% of male veterans are over the age of 60, (Katz, 2012). In addition,

1.8 million soldiers have deployed in combat operations in Iraq and Afghanistan since

(2011), state the Veteran Affair’s Medical Center’s long-term care facilities cannot meet overwhelming current demands and provide support for veterans with cognitive and physical deficits, who can no longer be cared for at home. They note it is imperative that immediate measures be taken to strengthen resources for research, manpower, and training to accommodate the relocation of aging veterans from home to long-term care.

Department of Veterans Affairs, 2012). Nevertheless, 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 a long-term care setting does not exist.

Statement of the Purpose

The purpose of this study was to develop a military-focused, occupation-based, cultural heritage intervention for veterans who recently transitioned to a LTC setting.

Military culture for the purposes of this study was defined as the manner in which military experiences shape an individual’s worldview (Kirchen, 2013). Military experiences influence the perspective of both the service member and his or her immediate and extended family. For example, on average, a military family relocates every two to three years, (Adler & Castro, 2013). They may live overseas and seldom live near extended family members, (Adler & Castro). Therefore, the worldview of a military family may be quite different than that of family who had lived in one geographical location for many generations. Occupation-based is defined as using functional activities in the participant’s natural environment as a therapeutic means as the belief that human engagement in meaningful, purposeful activities is essential to health and wellbeing, (Reilly, 1962).

be distinguished for the purposes of this study by associating person factors that relate to military experience as military culture and those that do not, as cultural heritage.

Description and Rationale for Intervention (OBCHI-MV) Methods

Methods include an explanation of the purpose of the six group sessions, a discussion of the meaning of each of the cultural heritage themes (Family, Home,

Spirituality, Military Role, Leisure and Food/Music) and a discussion or activity that relates the cultural heritage topic to military culture. The activity will represent each of the member’s cultural heritage/military culture. These methods were chosen to involve stimulation of auditory, visual, tactile, and kinesthetic senses. Use of these methods will increase activity participation, social interaction, and appreciation of each other’s cultural heritage and military culture.

Description and Rationale for Group Facilitator Role

1. Model behaviors and provide structure so group members feel safe and

comfortable.

2. Monitor any participant who may dominate the group process or who is not

participating; provide appropriate feedback, e.g. elicit other’s responses if one

person dominates.

3. Modify activity to match the participant’s needs.

4. Assist participants as needed, e.g. verbal cues, hands-on, additional explanations.

5. Set the mood for future sessions.

Specific Aims

The aim of this study was to incorporate the themes that emerged from study one, a qualitative phenomenological study based on the perspectives of ten veterans who had recently relocated to long-term care, into a military-focused, occupation-based, cultural heritage intervention. The themes were: Family, Home, Spirituality, Military Role,

Leisure and Food and Music. The basic premise for the intervention was that an individual’s culture empowers the person with meaningful rituals and beliefs which, given the opportunity, can be expressed and shared with others in a supportive social system. By engaging veterans/residents in small group interactions and meaningful activities based on their cultural traditions (both military and heritage based), a sense of connection with other group members can be fostered. By implementing the OBCHI-MV during the relocation period (within twelve months of the resident’s admission), the cultural heritage and military culture of each individual in the group is highlighted to promote the person’s adaptation to the facility. Measurement of the resident’s social participation, activity engagement, and quality of life are used to determine the level of adaptation. This study answered the following research question: Based upon the perspectives of veterans on adaptation to long-term care, what are the essential components of an intervention protocol?

Researcher’s Perspective

My research focus was military culture in relation to adaptation of aging veterans to long-term care settings. I believe occupational therapists have an opportunity to

conduct research that will guide practice and set the precedent for long-term care of veterans, both now and for years to come. I feel passionate about this topic because I was an enlisted soldier, an officer in the United States Army, and have been a military spouse and mother for the past sixteen years. In addition, I am currently the rehabilitation director for a state-funded veteran’s home in southeastern United States. I have experienced the benefits and challenges of military culture from multiple perspectives across the lifespan. I believe that experience gives me special understanding of these veterans and the issues they face as they relocate to long-term care facilities.

Background and Significance

Katz, (2012), a medical doctor at the Department of Veteran’s Affairs, states as of the end of 2010, 33% of America's living veterans had served during the Vietnam War era, 9% during World War II, 11% during the Korean War, and 25% during the Gulf War era that began in 1990. At the end of 2010, 43% of the Veteran men were older than 65 years old and 58% older than 60 years. Katz, (2012), emphasizes that veterans are distinguished by their history of service to their country, their training, and their membership in the unique culture shared by those in the profession of military service.

culture, the aging process for veterans must be studied and understood in a distinct manner from the civilian aging population.

Settersen, (2005), states that detailed data on military experiences are needed for research policy and practice. He also emphasizes the importance of understanding the impact of military service on later life as millions of veterans worldwide move through advanced old age and younger veteran populations move into old age. The profession of occupational therapy has the potential to significantly improve the quality of care for aging veterans through research and practice. Nevertheless, occupational therapy literature focusing on veteran adaptation to long-term care settings is currently non- existent.

Literature suggests that “being understood” and “feeling connected” to a facility is a key aspect of adaptation for older adults in LTC settings (Brandburg, 2007; Brooker, Woolley

& Lee, 2007; Moore, Delaney & Dixon, 2007; Guse and Masesar, 1999; Sorrell &

Durham, 2011). Therefore, research is needed to better understand the specific needs of veterans who transition to LTC facilities.

Occupational Therapy Interventions in Long-term Care

Hersch, G., Hutchinson, S., Davidson, H., Wilson, C., Maharaj, T., & Watson, K.

B., (2012), suggest that culture has an influential role in helping older adults adapt to life in long-term care facilities. Hersch et al., (2012), developed a group, cultural intervention to assist elders in adjusting to their new residential situation. The basic premise for the intervention was that an individual’s culture empowers the person with meaningful rituals and beliefs which, given the opportunity, can be expressed and shared with others in a supportive social system. By engaging residents in a small group interaction, and meaningful occupations, based on their cultural traditions, a sense of connection with other group members could be fostered.

The method of the study was a quasi-experimental, nonequivalent, control group design. Twenty-nine participants were given pre- and post-tests. Residents in the intervention group received a 4-week, cultural protocol-driven, intervention and were compared to the control group, who participated in groups with typical content such as crafts, etc. Measurement of the resident’s social participation, activity engagement, and quality of life was used to determine the level of adaptation. The results of the study revealed the effectiveness of a structured, occupation-based, group intervention that improved quality of life for participants. There were no significant differences, however, between the control and intervention groups.

Occupational Therapy Interventions and Wellbeing of Older Adults

One of the primary outcomes of this dissertation was to develop an occupation- based, cultural heritage intervention that facilitated adaptation of veterans to long-term care. Occupational therapy interventions have been effective in promoting the wellbeing of independent-living older adults as evidenced in the work of Clark et al., (2012). In this study, 460 men and women aged 60 to 95 years participated in a randomized controlled trial comparing an occupational therapy intervention to a no control condition over a six- month period. Results revealed that the intervention group showed favorable change scores when compared to the control group in the areas of pain, vitality, social functioning, mental health, composite mental functioning, life satisfaction and depression. The findings indicate that the intervention has the potential to assist in the reduction of health decline and increase wellbeing in older adults.

Adaptation in LTC

Yerxa, 1967). Lawton and Nahamow, (1973) define adaptation as a person’s relationship with his or her environmental context. Adaptation for the purposes of this study was defined as the process by which a veteran encounters a perceived challenge in his

environment and successfully manages that challenge as measured by increased quality of life, activity engagement and social participation, (Hersch, et al., 2012).

(Bol, & MacMaster, 2003; Chao et al., 2008; Hersch et al., 2004,). However, research that examines factors facilitating veteran-specific adaptation to LTC settings is not readily available, but it’s likely that these same indicators for older adults may be applied to an aging veteran population.

Military Culture and Adaptation

When one relocates from one setting to another setting, he or she attempts to assimilate his or her cultural practices and beliefs into the new setting. Hersch, et al.,

Adler and Castro, (2013), U.S. Army psychologists, developed a model entitled the Occupational Mental Health Model, (OMHM), a modification of the Soldier

Adaptation Model (SAM), (Bliese & Castro, 2003). The OMHM clarifies the occupation

of being a soldier. Alder and Castro state that in order to treat physical and psychological issues of redeploying soldiers, one must understand the military context from the perspective of the soldier. While other occupations have been well studied and are readily understood the culture of soldiering, is often only understood by those who are in the military.

Although occupational therapy literature related to the adaptation of non-military- related older adults in LTC settings was readily available, occupational therapy literature addressing veteran adaptation to long-term care was non-existent. Currently, there are no assessment tools or protocols for facilitating or measuring veteran adaptation to long- term care. The Occupation-based Cultural Heritage Intervention-Military Version

(OBCHI-MV) has the potential to increase the understanding of military culture amongst caregivers of veterans and facilitate improved adaptation to long-term care.

Methods

This study focused on developing a military-focused, occupation-based, cultural heritage intervention based on the results of a previous study which used a qualitative phenomenological approach to explore the person and environmental factors related to successful veteran transition and relocation to long-term care. Institutional Review Board

(IRB) approval was obtained from the university and the facility where the intervention took place prior to the initiation of participant recruitment. All participants gave informed consent prior to participation in the study.

Data Collection Procedures

The themes that emerged from qualitative interviews with the veterans were formatted into six protocol-driven group sessions following the Occupation-based

Cultural Heritage Intervention format, (Hersch et al., 2012). The Occupation-based

Cultural Intervention-Military Version (OBCHI-MV) combines military culture and other culturally relevant themes. It consists of a user-friendly, protocol manual containing six group sessions, developed to meet the needs of most aging veterans. See Appendix I.

For example, based upon the primary theme of family hardship during military deployments that emerged from the qualitative data, a protocol-driven, group session centered on “family” was developed to discuss ways family members stay connected both now and during deployments. The group activity focused on creating a written essay to a dedicated family member. The essay captured facts, dreams and the true essence of who the participant was. The essay was sealed in an envelope and given to the family

member. The group ended with a discussion of family and how we cannot always be together because of war, illness, etc., but we can share our love through letters, phone conversations, or visits.

Trustworthiness of the OBCHI-MV Protocol Manual

A panel of experts reviewed the protocol manual prior to implementation. The panel consisted of an administrative director in the veteran’s home, a licensed recreational therapist, an occupational therapy graduate student and a graduate student in psychology. The primary researcher made adjustments to the protocol based on feedback from the expert panel and did not transition to implementation of the protocol until consensus was reached.

Theoretical Bases for the Group Intervention

(Adapted from the OBCHI, Hersch et al, 2012-with permission)

Because the Occupation-based, Cultural Heritage Intervention-Military Version was conducted in a group setting, it is important to examine some frames of reference, assumptions, and concepts that guided the process. A basic definition of a group is: “an aggregation of people who share a common purpose which can be attained only by group members interacting and working together” (Mosey, 1973, p. 45).

Research in the following areas has been considered in the design of the groups that were conducted for the occupation-based, cultural groups (military version) include:

1. Group dynamics concern the dynamic interaction and the interrelationships

between members of the group. From these interactions, members derive multiple

types of support and feedback. These dynamics can support growth in individuals,

as well as opportunity to meet task, emotional, and social needs. As the group

members grow more comfortable with the group, there will be an increased sense

of “group” identity and resultant self-direction (Schwartzberg, Howe, & Barnes,

2008).

2. The concept of effectance motivation suggests that in a group setting an individual

is motivated to engage in interactions and transactions that can result in a sense of

competency, (White, 1959). If the occupations and environment match the

individual’s level of comfort, explorations of new ways of doing things can result

in an increased feeling of efficacy. Although it is assumed that this motivation is

innate, sometimes an individual, when met with too great a challenge or when

personal meaning is absent, can lose the belief in the expectation of efficacy and

this can lead to unwillingness to try new activities.

3. The needs hierarchy addresses a set of basic human health needs that must be met

for the person to experience a sense of wellbeing in all areas—physical,

psychological, and social, as described by Maslow, (1970). Thus, the group

member must experience a sense of physiological wellbeing, a sense of security,

and comfort and support in the group before being able to engage in the group

task and to achieve possible growth and pleasure in the occupation at hand.

4. Purposeful, occupation-based cultural activities are those that have meaning for

the individual, and lead toward goal-oriented behavior. There must be a match

between the individual's skills and opportunities for action in the environment,

(Schwartzberg, Howe, & Barnes, 2008). An ideal match between intrinsic

rewards and motivation can lead to an “optimal experience.” This is described by

Csikszentmihalyi, (1990) as a “flow state,” in which “concentration is so intense

that there is no attention left to think about anything irrelevant or to worry about

problems” (p. 17). This flow state is an ideal, but it is one the group members

should be able to expect at least some of the time.

5. “Adaptation through occupation….means the organization and management of

occupational activities and tasks in a manner that meets the goal of achieving

maximum…..actualization or satisfaction and accomplishment,” (Reed, 1984, p.

495). This supports the expectation that engaging in meaningful occupationally-

based cultural activities in the group setting can lead to an increase in adaptive

responses that will extend beyond the group activity itself. This is a premise

underlying the plan for this group series.

Results

This study reviewed and synthesized the qualitative results from participant interviews, which were then used to develop the protocol manual entitled, Occupation- based Cultural Heritage Intervention-Military Version (OBCHI-MV) (See Appendix I).

The following discussion highlights: participant demographics; qualitative interview findings; and the development of each chapter of the OBCHI-MV. The study concludes with recommendations for use of the OBCHI-MV and a summary section.

Sample

Ten participants completed the qualitative interviews in study one. See Table 1b for Demographics of the Sample.

Table 1b

Participant Demographics Table

Participant Age Ethnicity Military Combat Primary Branch/ Experience Medical Years of Diagnosis Service 1 88 Caucasian Air Force-20 WW II TBI 2 92 Caucasian Army-4 WW II Cancer 3 87 Caucasian Army-4 WW II Debility 4 60 African- Air Force-8 No Combat MS American Experience 5 90 Caucasian Army-4 WW II Leukemia 6 88 African- Army-30 Korean/ CVA American Vietnam 7 68 African- Air Force-4 No Combat CVA American Experience 8 64 Caucasian Army-20 Vietnam CVA 9 78 Caucasian Army/Navy- Vietnam CVA 22 10 92 Caucasian Airforce-4 Korean War Debility

Note: All participants were male, scored within a functional range on the SMPSQ (5 or >) and were taking a consistent (same dose/medication for over 6 weeks) dosage of medication to manage depression. Frequent is defined as at least 1 visit or outing per week.

Theme-based Module Development

Based on the findings from Study I, entitled, “Person and Environment Factors impacting Veterans' Adaptation to Long-term Care: A Qualitative Study,” veterans who reside in LTC settings, have an ongoing desire to revisit military experiences with other veterans; however, five of ten participants stated it was a challenge to locate other veterans within the facility who could converse on their level. All ten participants stated they have little or no control over their routine from day to day and nine of ten participants indicated they would like to be offered more choices, especially with food and activities. Veterans possess an innate desire to serve others, (Katz, 2012). The participants in Study I voiced a need to feel useful to family, the facility and the community at large.

Each of the six group module’s attempted to meet the above-mentioned needs of the participants, for example the Spirituality Session began with a group discussion related to how spirituality impacted their time in combat. One participant said, “You will never meet an atheist in a foxhole.” Participants were encouraged to make choices and have control over the session by selecting food, drink and music, options to participate or not, ask questions and change the discussion topic. The participants were able to give back to others by selecting a family member or friend to ask the Chaplain to pray for.

The themes are listed in the order of the highest to lowest frequencies that were coded in the interview transcripts. For example, “family” was coded more than any other theme. Each theme was developed into an individual group session. Participants

emphasized the following over arching themes as being important to them both in the past and present:

1. Family

2. Home

3. Spirituality

4. Military Role

5. Leisure

6. Food and Music (in relation to celebrations)

Specific participant interests and preferences were incorporated into each session, i.e. one participant stated that he would like to eat barbequed pig’s feet because it reminded him of his grandmother. The primary researcher ensured that barbequed pig’s feet were available for Session Six: Food and Music.

Session one-culture and family. (Theme supported in study I data). Participants emphasized family throughout the interview process. They described childhood experiences, traditions and relationships with family members. Participants also discussed family in the context of their military experience, i.e. wives waiting for husbands or parents worrying about the safety of soldiers/children. Family continued to be an important cultural theme throughout the lifespan of the participants. All ten interviewed participants discussed their family in the present context. One participant stated: “It’s when your children grow up to be healthy and happy that you know you have really achieved something,” (Participant 2).

Family was the most frequently discussed topic amongst all participants as noted in the interviews. Participants discussed family in the context of the past, present and future. They shared stories of when they were children, when they had their own children and now of their children’s children. Participants expressed strong emotions of pride and sorrow as family was discussed. In the initial interview, one participant shared that when he came home from Vietnam, after his third tour of duty, his wife’s attorney was waiting at the airport with divorce papers in hand. He lost custody of his two small children and he was not able to see them. Years later, his son died of a drug overdose. He has never forgiven himself.

The primary researcher and two research assistants who coded and ensured saturation of the interview data from study one, as well as the panel of experts who reviewed the OBCHI-MV Protocol came to consensus that family was an salient topic.

Sharing pictures of family members with the newly formed group was an icebreaker that allowed participants to become comfortable with one and other. The discussion questions addressed the topic of family in the past, present and future, as well as experiences both in and out of the military sector. It allowed participants to discuss and heal from some memories and rejoice and celebrate others. The discussion format from group session one from the OBCHI-MV Protocol is as follows:

"Now to begin this first group session, let’s describe what we mean by culture…who would like to start? [encourage each member to state what they think culture is; if there is difficulty getting the discussion going, provide a definition, e.g. culture is what we learn as we are growing up about our family’s background, the traditions we share, and the holidays, food, and music we have…it’s being part of a group that gives us an identity, comfort, and security]. "What other things are handed down by families? Do you sometimes see your mother, father, or grandparents in how you think or do things? Is there anything else about culture that you would like to share? For example, what about home remedies? Religious values? Disciplinary practices?”

"Now that we know what culture is, I’d like for each of you to tell the group one thing that you would like everyone to know about your own culture or cultural heritage. [If no one volunteers, then the group facilitator may start the discussion by providing an example from her own cultural background]."

“Great. Now, I would like to discuss families. Families are a big part of who we are. How do you define a family? What makes a family? (Discuss these questions for 3 to 5 minutes).

Military culture is defined as military experiences that shape one’s worldview

(Kirchen, 2013). Examples of military culture in the discussion included stress placed on the family due to frequent deployments, the impact of frequent family moves and the experiences families shared when stationed in other countries. Cultural heritage is defined as childhood experiences and exposure to other life situations that shapes preferences, how one chooses live, and what one believes. Participants discussed cultural heritage in the “Family” module in terms of how one was parented, how many children or siblings he had, and where his grown children live and how often they visited.

The activity for session one “Essay’s for My Family” was selected because it allowed participants to share memories and thoughts with a dedicated person of choice. It addresses participant’s cultural heritage and the military cultural needs because it allows the participant to create a document that captures past personal history (military and civilian) and ties it to the present and future, as the participant dedicates his thoughts and feelings to a designated loved one. Veterans often feel guilty about frequent separations from family due to military obligations such as war or prolonged training, (Adler &

Castro, 2013). The essay allowed participants to discuss and resolve these feelings, as well as create a family keepsake.

Session two: cultural heritage: what is home?(Theme supported in study

I data). During the interviews, participants were consistent in their feelings that the facility was not like home. They recognized their needs were met, but they did not relate that to being at home. Participants mentioned lack of privacy and comfort in the facility as being different from home; however, home was the second most frequently discussed topic. The primary researcher and two research assistants agreed that home was important to participants, but were concerned participants did not perceive the facility as home.

The protocol on home was developed to highlight the positive aspects of the facility by recognizing that other veterans in the community do not have consistent food, clothing or shelter. The activity highlighted this situation by facilitating a group effort to create a care package for a specific homeless veteran who was residing in a local homeless shelter. The participants selected donated items to place in the box and

concluded the activity by generating a letter to the veteran. The participants wrote statements such as, “You are not alone. If we can help you, let us know.” The rationale for Study Two is as follows:

Description and rationale for methods: Constructing a care package for a deployed soldier and/or a homeless veteran will emphasize the importance of having food, clothing and shelter. It may facilitate positive feelings about the facility when residents realize that despite not being at home, they do have their basic needs met. Writing a letter to the homeless veterans at the shelter will generate empathy and compassion for those veterans who do not have consistent food and shelter. The activity provides an opportunity for the participants to contribute to the community and do something for someone else.

Examples of military culture in the discussion included the variety of types of homes the military provides, such as on-post housing, tents, huts and sleeping on the ground, when conducting field missions/training. Participants discussed cultural heritage in the “Home” module in terms of what one’s childhood home was like, location of birth and specific amenities of their last home (prior to relocating to LTC).

The activity for session two was selected because it addressed both cultural heritage and military culture in that it facilitated a discussion that home is not as much about the facility as it is about the people who live within the structure. It also allowed the participants to take care of a fellow service member who was in need. One participant stated, “We never leave a buddy behind.”

Session three-spirituality. (Theme supported in study I data). Spirituality was strongly emphasized in eight of ten participant interviews. Participant religious beliefs

and practices are occupation-based because they embrace life roles and activities that are meaningful and fulfilling to the participant. For example, participants described teaching

Bible classes, becoming an ordained deacon and attending church as a child and adult.

Interestingly, eight of the ten participants stated they did not regularly attend church while they were in the military. The military offered services, but service members often worked on Sundays or were in wartime situations not conducive to attending services.

However, one participant stated: “You won’t find an atheist in a foxhole. We might not have been able to go to church, but we were sure praying” (Participant 9). Nine of ten participants stated they relied on prayer and their connection with God to cope with the challenges of being away from home, particularly when in combat situations.

Discussion of the session development. Six out of ten participants cited from the interviews the facility chaplain as the person they would be most likely to contact if they had an issue or a concern. As such, the research team invited the chaplain to lead the session on spirituality. Participants became more comfortable with the chaplain and sharing their views on Christianity. In addition, newly admitted veterans were informed of the various religious services held within the facility and when the chaplain was available for office calls. Developing a connection between spiritual needs, facility religious services and support from the chaplain increases the likelihood the veteran will begin to feel more comfortable and satisfied within the LTC setting.

Examples of military culture in the discussion included what religious beliefs and practices service members engaged in during wartime situations and how significant the

belief in a higher being was in maintaining their psychological wellbeing during war.

Participants discussed cultural heritage in the “Spirituality” module in terms of how one was raised, which church he belonged to, and what beliefs he held in relation to death and dying.

The activity for session three “Spirituality” was selected because it allowed participants to pray for a loved one and meet with the facility Chaplain, who was able to share religious service times and answer many questions participants had related to death.

Military culture and cultural heritage were interwoven in this session. For example, one participant asked the Chaplain if God would forgive him for all of the innocent people he inadvertently killed when he was performing air-bombing missions in WWII. Many of the participants were over eighty, with multiple medical conditions and asking questions about death and dying was important to them.

Session four: military role. (Theme supported in study I data). In nearly all aspects of the interviews, participants discussed their role in the military. They described the places where they had been and the specific job they held. The varying number of years in service did not affect the participant’s ability to recall the details of the positions he held while serving his country. All ten participants reported having had both positive and negative experiences while in the military, but each of the participants stated if he had to do it all over again, he would, without a doubt, choose once again to serve his country.

Discussion of the session development. The unifying element for participants in study one was military service to country. Eight out of ten participants served under combat conditions. Discussing military experiences with other veterans is an important pastime for most prior service members, (Sorrel & Durham, 2011), as such the primary researcher and the research assistants incorporated activities within the session to facilitate discussion.

Examples of military culture in the discussion included a detailed description of each participant’s role while serving in the military, as well as number of years served, branch served under and locations of military assignments. Participants discussed cultural heritage in the “Military Role” module in terms of how personal beliefs and family culture and traditions impacted the choice to stay in the military or how one coped with the military experience, examples include a participant who stated, “I would have stayed in the Army longer, but I wanted to get back to my wife.” Another participant stated,

“My dad taught be to be adventurous, so the military was a good fit for me.”

The activity for session four “Military Role” was selected because it facilitated conversation and connectedness amongst participants and also improved staff-member understanding of various roles of service members. A trivia game was developed using the military occupation of each participant as a question. For example, “What do you call the service member who prepares the meals?” The answer is, “What do you call a military cook.” In addition, items used in military occupations were placed in a duffle bag. Participants took turns pulling items from the bag and discussing the use of each

item to complete a specific job. The session concluded with the group facilitator encouraging participants to continue to seek out meaningful roles and responsibilities within the facility and the community. The participants brainstormed ideas for

“jobs/responsibilities” that they could complete in the LTC Setting, which united military culture with cultural heritage because participants had to consider current needs of the facility with personal abilities.

Session five-leisure activities. (Theme supported in study I data). All but one participant discussed leisure activities in the past tense. They described activities engaged in while in the military or civilian sector. All of the participants related physical dysfunction with an inability to participate in leisure activities of choice. One person voiced his frustration with not being able to use his right arm due to a stroke. He said:

“One minute I was fine. The next minute I was lying on the floor and my world changed forever. I couldn’t fish or play softball. You just want to quit life when you can’t do anything anymore,” (Participant 8).

Examples of military culture in the discussion included a detailed description of leisure activities that were performed while in the military. Leisure-time activities tend to be an important aspect of the military lifestyle. Service-members engage is social activities such as card playing or sports to pass off-duty time when deployed, (Adler &

Castro, 2013). Participants discussed cultural heritage in the “Leisure” module in terms of activities or sports that were engaged in as a child, adult and now as a resident of the

LTC setting.

Engaging in meaningful activities of choice is essential to obtaining quality of life, (Yerxa, 1967). Residents who transition to LTC, usually possess cognitive or physical limitations that interfere with their ability to engage in meaningful leisure activities as they once had. Facility restrictions coupled with veteran disability can marginalize leisure time activities/opportunities for newly admitted veterans.

Nevertheless, simple adaptations and modifications of the activity and the environment can facilitate veteran engagement in meaningful activities. This session provided a wide variety of activities such as horseshoes, basketball, cards, etc., that veterans may have enjoyed in the past.

The group facilitators and research assistants demonstrated how a simple cardholder could be used to hold cards for a participant who had lost the ability to move his left side due to a stroke. Participants were able to be successful and independent with leisure activities of choice, many of which they had not been able to participate in for years due to physical limitations.

Session six-food and music in relation to celebrations. (Theme supported in study I data). Food was discussed in seven of ten interviews. Participants most often discussed food as it related to childhood memories, such as one participant who had a

German mother who cooked schnitzel. He reminisced: “My mother used to make me the most wonderful schnitzel. I haven’t had it in years, and I sure do miss it,” (Participant 8).

Another participant, raised by his grandmother, described eating barbeque pig’s feet every Sunday. The participants described food as having a strong connection to family and home.

In addition, participants engaged in worldwide travel via frequent military deployments. Participants described eating Korean, German, Italian and Filipino food during their time in service. Participants reported continuing to enjoy eating foods from the countries in which they had spent time. However, six of ten participants commented on the current inability to access foods of choice due to dietary restrictions or facility limitations. Dining family-style with fellow soldiers, airmen or sailors, is an important aspect of military tradition. Meals are usually eaten in dining facilities when not in combat and in tents or el fresco when in combat situations. Formal military gatherings such as promotion ceremonies, welcoming new personnel and fair welling departing service members are always accompanied by military traditions centered on food and drink.

Six participants commented on the importance of music either in their past or present lives. One participant sang in the church choir. Another participant listened to

Big Band music in his room every afternoon. Music was also strongly associated with holidays and celebrations. One participant sang military cadence during his interview.

Military cadence is used to facilitate marching maneuvers or during exercise when soldiers run in formation.

Examples of military culture in the discussion included food eaten while serving over seas, food eaten while serving under wartime conditions and music associated with military service. Participants discussed cultural heritage in the “Leisure” module in terms of activities or sports that were engaged in as a child, adult and now as a resident of the

LTC setting.

Veterans noted lack of choice and control as being an interfering factor with feeling at home in the facility. The researchers incorporated each participant’s food of choice and music preference into this session. The food choices for the implementation of the OBCHI-MV for Session Six included: schnitzel, tostadas, barbeque pig’s feet, fried cat fish and Korean food. Music choices included: Big Band, Country, Gospel and

Oldies Rock. Incorporating personal preferences of each resident into the session sent the message that each person was important. The formal setting of the table depicted the

formal settings at military gatherings and celebrations. The food was served in a family- style manner, which facilitated conversation amongst participants. Participants listened to music and seemed to enjoy one another’s company.

Discussion

It was the intent of this study to develop an intervention protocol to explore military culture and the occupation-based cultural intervention approach with veterans in a residential setting. The basic premise for the cultural group intervention is that an individual’s culture empowers the person with meaningful rituals and beliefs, which can be expressed and shared with others in a supportive social system. Engaging residents in small group interaction and meaningful occupations based on their cultural traditions can foster a sense of connection with other group members. Figure 1 depicts two World War

II Veterans getting acquainted during implementation of the OBCHI-MV. These veterans had much different childhoods and life experiences, but shared a common bond of service to country, which united them from the first meeting.

Figure 1: Two WWII Veterans get acquainted

Administration of the OBCHI-MV (Non-research Version)

The OBCHI-MV is to be used in conjunction with the Military Culture and

Lifestyle Interview for Long-term Care-Interview Guide, (Kirchen, 2013). Veterans should be interviewed within the first week of transitioning to the LTC facility. The veteran’s interview responses/preferences can be incorporated into the OBCHI-MV group activities, if possible. For example, if the participant enjoys Big Band music or watermelon, the group sessions could include these participant preferences. The OBCHI-

MV requires between three and five participants to commence. Veterans should be invited to participate, but it is the veteran’s right to decline group participation, if he so chooses. The veteran should be informed that he is always welcome to join the next group session, if he changes his mind.

Activity and therapy departments, as well as social workers, could foreseeably use the OBCHI-MV to facilitate adaptation of veterans to LTC. The total time to complete the interview, group sessions, and participant feedback survey, is approximately 15 to 20 hours. The protocol manual contains six, forty-five minute sessions. The sessions require time to obtain materials and prepare the group setting. It may require 30 minutes to 1 hour to prepare for each session. It is recommended the group facilitator have additional personnel to support group members. One assistant to two participants is recommended.

It is important each veteran feel successful and competent during the sessions. Physical limitations may require adaptations or modifications to maximize function. If a group facilitator is not able to adapt a task to allow for participant success, the rehabilitation

department could be consulted, as they may be able to provide adaptive equipment or other helpful suggestions.

Limitations

One of the limitations of this study is that it was implemented using a small sample size of eleven participants from one facility. Another limitation of the study/intervention is the preparation time and cost of materials required to complete the group sessions. Newly admitted residents may not be willing to participate in the group sessions until they feel comfortable with facility staff and routines. Coordinating group sessions are challenging due to resident medical appointments, therapies, etc. Group facilitators must be comfortable with leading groups and adapting activities for veteran success in the sessions. Some group topics may be upsetting to veterans.

Summary

The OBCHI-MV is based on the person and environment factors that contribute to veteran’s transition to long-term care. Implementing the OBCHI-MV within a year of when the veteran enters the facility allows the staff to understand and embed the resident’s cultural heritage into facility activities and to facilitate military cultural cohesion amongst newly admitted and existing veterans. The power of the intervention lies in its potential to ignite the military cultural bond between veterans that creates a sense of unity, belongingness and support. In addition, non-military affiliated staff members who use the OBCHI-MV with veterans have the benefit of gaining increased

knowledge and understanding of military culture. Military cultural awareness is invaluable in assisting newly admitted veterans with adaptation to long-term care.

CHAPTER V

STUDY THREE

Statement of the Problem

Currently, 43% of male veterans are over the age of 60, (Katz, 2012). In addition,

1.8 million soldiers have deployed in combat operations in Iraq and Afghanistan since

Sorrell and Durham, (2011) state the Veteran Affair’s Medical Center’s long-term care facilities cannot meet overwhelming current demands and provide support for veterans with cognitive and physical deficits, who can no longer be cared for at home.

They note it is imperative that immediate measures be taken to strengthen resources for research, manpower, and training to accommodate the relocation of aging veterans from home to long-term care.

Department of Veterans Affairs, 2012). Nevertheless, 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 a long-term care setting does not exist.

Statement of the Purpose

The purpose of this dissertation 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. This chapter describes the third study in a series of three, which resulted in the development and implementation of a military-focused, occupational-based, cultural heritage intervention, (Hersch, et al., 2012), with veterans who had recently relocated to a LTC setting. 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.

Definition of Terms

Military culture for the purposes of this study was defined as; the manner in which military experiences shape an individual’s worldview, (Kirchen, 2013). Military experiences influence the perspective of both the service member and his or her immediate and extended family. For example, on average, a military family relocates every two to three years, (Adler & Castro, 2013). They may live overseas and seldom live near extended family members, (Adler & Castro). Therefore, the worldview of a military family may be quite different than that of family who has lived in one geographical location for many generations.

Occupation-based is defined as using functional activities in the participant’s natural environment as a therapeutic means as the belief that human engagement in meaningful, purposeful activities is essential to health and wellbeing, (Reilly, 1962).

Hersch et al., (2012), defined cultural heritage as the learned beliefs, customs, actions, communication and life ways of a person. A veteran’s cultural heritage may be influenced by childhood traditions, religious beliefs or other life experiences that shape the unique person who he or she has become. Military culture and cultural heritage can be distinguished for the purposes of this study by associating person factors that relate to military experience as military culture and those that do not as cultural heritage.

Premise for the intervention

The basic premise for the intervention was that an individual’s culture empowers the person with meaningful rituals and beliefs which, given the opportunity, can be expressed and shared with others in a supportive social system. By engaging veterans/residents in small group interactions and meaningful activities based on their cultural traditions (both military and heritage based), a sense of connection with other group members can be fostered. By implementing the OBCHI-MV during the relocation period (within twelve months of the resident’s admission), the cultural heritage and military culture of each individual in the group will be highlighted to promote the person’s adaptation to the facility. Measurement of the resident’s social participation, activity engagement, and quality of life will be used to determine the level of adaptation.

Hersch et al., (2012), defined adaptation as: a normal process in which a person

encounters a perceived challenge in the environment and successfully manages that challenge.

Specific Aims

This study implemented the OBCHI-MV (intervention) and determined via pre- and post-tests whether or not the intervention improved participants’ adaptation as measured by quality of life (QOL), activity engagement and social participation. The conceptual foundation of this study is based upon the work of Hersch et al., (2012), who state that adaptation can be measured by increased quality of life, activity engagement, and social participation.

This study answered the following research question: Does the OBCHI-MV improve the participants’ adaptation to LTC as measured by QOL, social participation and activity engagement?

Background and Significance

Katz, (2012), a medical doctor at the Department of Veteran’s Affairs, states as of the end of 2010, 33% of America's living veterans had served during the Vietnam War era, 9% during World War II, 11% during the Korean War, and 25% during the Gulf War era that began in 1990. At the end of 2010, 43% of the Veteran men were older than 65 years old and 58% older than 60 years. Katz, (2012), emphasizes that veterans are distinguished by their history of service to their country, their training, and their membership in the unique culture shared by those in the profession of military service.

Due to combat exposure, veterans experience service-related mental and physical

suffering and disability that differs from the civilian population. The disabilities experienced by veterans, coupled with the aging process, affect veterans in different ways at different periods in their lives. Katz contends that because veterans are part of a unique culture, the aging process for veterans must be studied and understood in a distinct manner from the civilian aging population.

Settersen, (2005), states that detailed data on military experiences are needed for research policy and practice. He also emphasizes the importance of understanding the impact of military service on later life as millions of veterans worldwide move through advanced old age and younger veteran populations move into old age. The profession of occupational therapy has the potential to significantly improve the quality of care for aging veterans through research and practice. Nevertheless, occupational therapy literature, focusing on veteran adaptation to long-term care settings is currently non- existent.

Quality of Life in Long-Term Care

Social isolation, environmental deprivation, and a lack of meaningful occupation can intensify depression and other disabilities in older adults, (McKenna, Broome, &

Broome and Liddle, (2007), examined time use in relation to role participation and life satisfaction in older adults aged 65 and older. The study was conducted within the

community setting. It suggested older adults’ occupations and roles are diverse and age does not reduce occupation or role engagement. The study concluded that facilitating participation in valued roles was important to an older adult’s quality of life.

Literature suggests that “being understood” and “feeling connected” to a facility is a key aspect of adaptation for older adults in LTC settings (Brandburg, 2007; Brooker, Woolley

& Lee, 2007; Guse and Masesar, 1999; Moore, Delaney & Dixon, 2007; Sorrell &

Durham, 2011). Therefore, research is needed to better understand the specific needs of veterans who transition to LTC facilities.

Adaptation and LTC

Relocating from one’s home to long-term care involves adaptation because it includes leaving behind family, friends, routines, community groups, pets etc. The concept of adaptation has been used in occupational therapy research and practice as a means and an end when providing authentic occupational therapy, (Frank, 1996; Schultz

measured by increased quality of life, activity engagement and social participation,

(Hersch et al., 2012).

Military Culture and Adaptation

When one relocates from one setting to another setting, he or she attempts to assimilate his or her cultural practices and beliefs into the new setting. Hersch et al.,

Adler and Castro, (2013), U.S. Army psychologists, developed a model entitled the Occupational Mental Health Model (OMHM), a modification of the Soldier

The demands of killing, avoiding being killed, caring for the wounded, and witnessing death and injury are all part of military service. Additional military

occupational demands include frequent relocation, separation from family, and twenty- four/seven availability. While other occupations may have similar demands, the demands identified here are salient features of military service, (Adler & Castro, 2013). Civilian health-care providers, who treat veterans, whether it is in a military setting or civilian sector, rarely understand military culture, (Adler & Castro). This study has the potential to increase the understanding of military culture amongst caregivers of veterans transitioning to long-term care and provides an intervention to facilitate improved adaptation to long-term care.

Research Design

This intervention study used a quantitative approach with pre- and post-tests to test the research question. In particular, it used a one group pre-test, post-test design, which involved obtaining a baseline of participant depression, QOL, health status (mental and physical) activity engagement and social participation. Next, the intervention was implemented. Finally, post-tests were conducted to evaluate the change scores between pre and post-tests.

Environmental Component of the Intervention

Ten of twelve intervention groups were held in a large gazebo overlooking patient gardens. The gazebo was decorated in a comfortable manner with furniture, plants, tables with linens and decorative items: such as candles, lanterns and baskets. Music was played at the beginning and ending of each session and seasonal fruits and other

refreshments were served at the conclusion of each session. See Figure 2. Two of the twelve sessions were held in a large conference room due to rain.

The primary researcher constructed a multi-sensory experience for participants.

The gazebo, where the sessions were held, overlooked patient-tended gardens. The tables inside the gazebo were filled with fresh flowers, cut mint and herbs, such as basil to provide a familiar aroma. Patient-selected music was played at the beginning and ending of each session and the patients reported feeling the warm sunshine and soft breeze while outdoors. These sensory experiences can be associated with a soothing, comforting setting that likens itself to the feel of home. Ten out of eleven participants reported enjoying the opportunity to go outside on a consistent basis, while participating in the study. The primary researcher sought to create an environment for the intervention that would facilitate connectivity of the participants to the facility. The environment was a component of the intervention, not a separate variable, for the purpose of this study.

Figure 2: Photos of the Multisensory Intervention Environment

Participant Selection 88

This study used purposeful sampling and consisted of eleven male, long-term care residents who were admitted to a state veteran’s home within twelve months or less of the start of the study. The primary researcher recruited the participants. Ten of the eleven participants were in occupational or physical therapy or had been in therapy after admission to the facility at the time of recruitment. Ten of the eleven participants also participated in Study One of this dissertation. Institutional Review Board (IRB) approval was obtained from the university and the facility where the intervention took place prior to the initiation of participant recruitment. All participants gave informed consent prior to participation in the study.

The participants were between the ages of sixty and ninety-two years of age with a mean age of 82.27 years and scored a five or better on the Short Portable Mental Status

Questionnaire (SPMSQ), (Pfeiffer, 1975), prior to selection. The mean participant score for this sample on the SPMSQ was 95.45%. Nine of the eleven participants scored ten correct out of ten possible on the SMPSQ.

The sample was randomly divided into two groups to ensure optimal success with the activities. All eleven participants had physical limitations and required adaptations and/or assistance to participate in the group activity. The primary researcher assigned research assistants to assist participants (one research assistant per participant), as needed during group sessions. Since eleven participants in one group, would have been difficult to manage and not conducive to small group dynamics, the participants were randomly divided into two smaller groups of five and six participants. Three participants

from group one routinely participated in group two also. However, they engaged in the discussion, but opted to observe the activity portion of the session, meaning the research assistants still had a manageable group size. The groups were held at 9:30 am and 10:30 am on set days of the week. The second group session was easier to facilitate because if issues occurred with the activity, changes could be made prior to the second session, for example, during the trivia game (first group), the projector did not work correctly and several of the trivia questions were too recent to be appropriate for the participants.

However, the group facilitator was able to contact the facility media staff and the projector was functional for the second group and the current questions were not included in the second session. The intent of this study was to recruit and include thirty participants; however, the availability of participants was limited. One participant participated in the intervention study, but did not participate in the qualitative study.

Tools

The tools used for the pre and post-tests are listed in Table 3.

Table 3

Pre- and Post-Test Tool Description

Tool Purpose Reliability/Validity Author/s Yesterday (Moos & Used to measure activity A study by Horgas et al. (1998) reported Interview Lawton, engagement and social good interpreter reliability for activity (YI) 1984) participation. codes and domains with ks > .80.

Geriatric Yesavage Used to assess for Consists of 15 questions with yes or no Depression JA, Brink depression in the geriatric response. A score of > or = 5 indicates Scale TL, Rose population. depression. Research indicates good (Short TL, Lum O, reliability scores when compare to the Form) Huang V, GDS (Long Form). Adey MB, Leirer VO: Developmen t and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research 17: 37-49, 1983

SF-12 (Jenkinson, Used to assess physical It has excellent reliability and validity, C., Layte, and mental health status with the physical and mental function R., component scores being highly Jenkinson, predictive of the scores obtained from D., the full SF–36 (Ware & Sherbourne, Lawrence, 1992). K., Petersen, S., Paice, C., et al., 1997) QLI Ferrans, C. Measures quality of life The overall QLI scores can range from 0 Nursing E., & of residents who reside in to 30. Internal consistency for the total Home Powers, M. LTC. QLI scale has been described in 26 Version J. (1992) studies and is supported by Cronbach’s as ranging from .84 to .98 (Ferrans & Powers, 1985).

SCES (Moos & The original SECS Internal consistencies (Cronbach’s a) for Personal Lemke, assessment consists of 63 six of the seven subscales were Growth 1984) items but was adapted to acceptable to high (as 5 .59–.79), and the Questions an18-item form for this Resident Compiled- study. The SCES Influence subscale indicated moderate modified measures the influence of internal consistency (a 5 .44; Moos & environment Lemke, 1984).

Data Collection Procedures

Data collection was conducted over a span of five weeks. Once the participant group of eleven individuals was recruited and had completed pre-tests, the intervention commenced. The intervention consisted of six group-sessions, two sessions per week, for three weeks with one group of six participants and the second group with five participants. The sessions used a protocol-based intervention developed from the primary themes that emerged from the qualitative study. Post-tests were administered to each participant within one week of the conclusion of the intervention. Comparison of pre- and post-test data was conducted to determine whether the intervention was effective in improving the participants’ QOL, social participation, and activity engagement.

Managing Bias and Securing Data

The primary researcher trained two research assistants on administration procedures for the standardized assessments. The research assistants who administered the pre and post-tests were blinded to the purpose of the tools and scoring criteria. In addition, the primary researcher trained two additional graduate-level research assistants on the facilitation process of the group sessions. The group leader for both group sessions on the first day of the week was in the process of obtaining a post-graduate degree in psychology. The group leader for the second set of sessions was a teacher with a Master’s in Education. The researcher controlled for differences in group leader approach by ensuring participant groups had exposure to both group facilitators. Four additional research assistants were present for each group to assist participants with the activity or to

transport patients to and from the group session, as needed. The primary researcher provided research assistant training and oversaw the research process, but did not administer or score pre or post-test tools.

The assessment tools, audio recorder and field journal were returned to one graduate student researcher who scored and secured the forms and other materials in a locked file cabinet. The filing cabinet was located in the primary researcher’s office. The graduate student, who was blinded to the purpose and scoring of the tools, managed the organization of the filing cabinet and secured the key. The primary researcher did not have access to the research tools (pre- or post-) until after the raw data had been computed and documented.

Data Analysis

The statistical test used to analyze the pre- and post-test scores was the Wilcoxon

Signed Rank Sum Test (the non-parametric equivalent of a dependent samples t-test) and is 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; Small is d=.20, Medium is d=.50 and Large is d=.80,

(Kielhofner).

Results

This study provided the quantitative results from the implementation of the

Occupation-based Cultural Heritage Intervention-Military Version, (OBCHI-MV)

developed in Study Two. This section includes the following: a description of participant demographics, statistical analysis of the pre- and post- tools along with the descriptive data from the Yesterday Interview and the Participant Post-Intervention Feedback

Survey.

Sample

Eleven participants completed the intervention and pre- and post-tests. Nine participants attended each group session at least once. Two participants attended five of six sessions and two participants attended five of the six sessions twice.

See Figure 2.

Table 1C

Participant Demographics Table

Change in all measures (except the YI) from pre- to post- intervention was evaluated using the nonparametric Wilcoxon Rank Sum Test, which is the non-parametric equivalent of a dependent samples t-test. Additionally, within group effect sizes

(Cohen’s d) were calculated. Pre- and post- intervention changes were considered meaningful when they were either statistically significant at p < .05 or they suggested moderate effect sizes (Cohen’s d=.20-Small, .50-Moderate, .80-Large). 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) 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). See Table 4.

Table 4.

Means and standard deviations of outcome variables at baseline and post intervention followed by results of the Wilcoxon Signed Rank Sum Test (N=11)

Notes: *=p< .05; all significance tests are for Wilcoxon Signed Rank Test. GDS=Geriatric Depressions Scale ), SCES=Sheltered Care Environmental (Ind=Independence, SE=Self Exploration), SF-12=Standard Form-12 (PCS=Physical Component Score, MCS=Mental Component Score, QOL Tool=Quality of Life Index- Nursing Home Version, (HF=Health and Finances, SOC=Social, Psp=Psychological, Fam=Family

Descriptions of Results from Each Tool

The Geriatric Depression Scale, (Yesavage et al., 1984), revealed a p value of 0.78 and a

Cohen’s d of 0.12, meaning there was a slight improvement in the depression scores from pre to post test, but it was not significant. The length of the intervention may not have

been long enough to facilitate a significant change in depression scores. The intervention lasted three weeks and six to eight weeks may have been more beneficial.

The Sheltered Care Environmental Scale, (Moos & Lemke, 1984), contained the

Independence (how independent the participant feels in the environment) and the Self

Exploration (how comfortable the participant feels exploring the environment) sub-tests.

The p scores were not significant at 0.27 and 0.55. However, the effect size was small for Independence and moderate for Self Exploration.

The Standard Form-12, (Jenkinson, et al., 1997), contains a Physical Component Score and a Mental Component Score, which address how healthy the participant feels. The participant p scores were not significant at 0.08 and 0.17. However, the effect size for the physical component was moderate (0.74) and the effect size for the Self-Exploration

Component was small at 0.42.

The Quality of Life Index-Nursing Home Version, (Ferrans & Powers, 1985), contains subtests for Health and Finances, Social, Psychological and Physical and Family.

None of the p scores were significant for any of these measures and the effect sizes for

Psychological and Physical, and Family were small at 0.24 and 0.27.

The Yesterday Interview was administered prior to the commencement of the intervention and again following the intervention; as such documented leisure time does not include group activity time. Participants were asked to describe the day before, where there were when they engaged in a particular activity, who they were with and then rate how much they enjoyed engaging in that particular activity. The data was coded and analyzed by the primary researcher and one research assistant. The coding was completed separately and then the researchers met and reached consensus on codes to ensure accountability. The primary codes were (1). Leisure activities, (2). Self Care, (3). Rest and (4.) Social Participation. These categories were then defined as being obligatory or discretionary activities. Obligatory activities are defined as; activities required in maintaining one’s health and wellbeing such as taking a shower or cooking a meal.

Discretionary activities are activities one chooses to engage in such as reading a book or playing Bingo. In order to simplify outcomes, the researchers narrowed the focus to pre- and post-intervention frequency and time spent participating in social or solitary activities.

See Figure 3 for YI results. As noted, greater time was spent in leisure participation following the intervention. Specifically, there was a 24% increase from pre-test to post- test in leisure-time activities.

Pre and Post-Test Use of Leisure Time Yesterday Interview

Total Time in Hours

Obligatory

Discretionary Activities Performed Alone Leisure Time Pre-Test Social Activities Leisure Time Post-Test 0 20 40 60 80 100

Activities Social Total Time in Performed Discretionary Obligatory Activities Hours Alone Leisure Time Pre-Test 13 12 22 3 63 Leisure Time Post-Test 19 14 27 5 84

Figure 3: Pre and Post-test Use of Leisure Time

Post-intervention Feedback Surveys

Ten of eleven participants completed post-intervention surveys. The survey asked participants to complete the following statement, “Since I began participating in the group sessions, I have thought more about______.” The statement was completed using the sessions’ cultural heritage topics such as: home, family, leisure activities, etc.

The participants were given the response options of; 5-Agree, 3-Doesn’t Matter or 1-

Disagree. The survey also asked the participant to comment on what he liked most and least about the group sessions. One research assistant completed all surveys within three days of the completion of the last group activity. See Figure 4.

Participant Post-Intervention Feedback n=10

Participant Responses Cultural Heritage Topic DON'T CARE

Military Lifestyle Home/Family

DISAGREE Military Work Leisure Music Food AGREE

0 2 4 6 8 10

Question: Since beginning these sessions, I have thought more about______. (Cultural Heritage Topic)

Figure 4: Participant post-intervention feedback

Participants responded with 90% agreement that they thought about the military lifestyle more since participating in the groups. Similarly, 90% of the participants agreed they thought more about leisure activities. Participants reported an 80% agreement that they thought more about Music, Home and Family since engaging in the groups. Sixty percent of participants reported thinking more about food and four participants stated they did not care about food or the impact it had on the sessions. “Thinking more” about 100

leisure activities may mean that patients may find ways to engage in more leisure time activities. The fact that participants are thinking more about their role in the military may mean an increase in social participation as veterans converse with other veterans about military experiences.

Eight of the participants expressed that they enjoyed the groups as they were designed and would not change anything. One of the participants stated that he would have preferred if the group sessions had been held in the afternoon, rather than the morning. Another participant noted that he would have liked more opportunities to discuss military traditions of the past and present. Interestingly, both participants who had suggestions were from group session one, which was less efficient than group two because it was the first time for implementation. All ten participants commented on what they enjoyed most about the sessions. Nine of the ten stated they enjoyed spending time with others who not only understood, but could communicate with them. Other comments included; “…enjoyed being outside, liked playing basketball and other modified activities, enjoyed eating a family-style meal with folks who could talk to me while I ate.”

Military-Focused Group Sessions

The group sessions were military-focused because each session included a discussion and an activity that encouraged the participants to remember and share their military experiences with the group. For example in the “Spirituality” session, the discussion included; what religious beliefs and practices service members engaged in

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during wartime situations, and how significant the belief in a higher being was in maintaining their psychological wellbeing during war

Military culture and cultural heritage were interwoven in this session. For example, one participant asked the Chaplain if God would forgive him for all of the innocent people he inadvertently killed when he performed air-bombing missions in WWII. Many of the participants were over eighty, with multiple medical conditions; asking questions about death and dying was important to them.

Discussion

This discussion section will unite the findings from the research tools into a meaningful summary that provides recommendations for LTC staff who care for veterans. First the importance of the environment is discussed. Next, the significance of ensuring veterans have control over their time use and are allowed to make choices is presented. Finally, the need for veterans in LTC to continue to be a viable and useful participant within the facility and the community is discussed.

The research question asked: Does the OBCHI-MV intervention improve quality of life, activity engagement and social participation as measured by improved pre and post-test standardized tools? The pre- and post-tests measuring activity engagement, social participation and quality of life were administered to measure the effectiveness of

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the intervention. 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.

Sense of Home

Participant comments on the Feedback Survey revealed that nine out of ten participants valued being outside in a home-like setting for the groups. Home is a place where visual, auditory, tactile, and olfactory senses are stimulated or calmed by what is familiar. Home is comfortable and welcoming. We eat the foods we enjoy, listen to music of choice, and surround ourselves with people, pets, furniture and decorations that bring us comfort and add quality to our lives. Veterans who have recently transitioned from home to long-term care have left behind their homes, families, pets, yards, friends, etc. Incorporating participant-identified preferences for food, music, etc. into the intervention and creating a home-like environment in which to host group sessions was reported as important to nine of ten participants.

In order for the veteran to develop a sense of connectedness to the facility, staff must facilitate a sense of belonging for the resident. When possible, the facility should appear home-like, rather than sterile and unwelcoming. Plants, warm colors and comfortable furniture were participant recommendations. Participants preferred having a

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private room, large enough to hold a bed and recliner from home. If that is not possible, residents could bring smaller items from home such as framed family photos, bedding, and other items to make the room feel comfortable and familiar. Common areas within the facility should mirror a home-like appearance as much as is possible.

Brereton et al., (2012), note the environment can profoundly affect the health, wellbeing and quality of life of older adults. They conducted a systematic review of studies examining the impact of hospital environments on older, end of life patients. Ten studies met the inclusion criteria and four themes emerged; privacy as needed, physical and environmental proximity to loved ones, connection with home and family and a satisfaction with the physical environment. The study suggested that patients had better quality of their final days when the environment was pleasing and home-like to them.

Suggestions. Activity and therapy departments should welcome resident family and friends and develop opportunities for positive interaction to occur on a consistent basis, i.e., hosting a picnic in the gazebo, a party or an outing where resident’s families and friends are invited to participate. Families should be allowed to bring pets of residents to the facility, if the pet is leashed and friendly. Use of therapy dogs and facility-housed fish or birds is helpful for residents who have left a beloved pet behind.

Residents who enjoyed gardening and spending time outdoors should have the opportunity to go outside on a daily basis. The resident should be encouraged to assist with the care of the facility plants, flowers and gardens, if that is something he or she enjoys.

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Time use. Veterans tend to be most comfortable with a stringent routine. (Jackson et al., 2012). Transitioning to LTC forces the newly admitted veteran to alter his routine and adapt to the structure of the facility. Meals are eaten at a certain time. Safety policies mandate veterans must have an escort in order to go outside. The veteran must conform to the rules and regulations of the setting, in order to engage in obligatory and discretionary activities. One participant annotated on the Post-Intervention Survey, “I really enjoyed being outside. I haven’t been outside in six weeks. I can’t seem to find anyone to take me.”

Adolph Meyer, (1866-1950), a psychiatrist and a strong influence for the development of the profession of occupational therapy, found healthy behavior could be organized by “doing” within the context of normal life habits and routines, (Meyer,

1982). Meyer, (1982), also noted that mental illness was a result of a maladaptive fit between an individual and his or her environment. Incorporating veteran’s personal habits and routines into the LTC facility schedule may increase the likelihood he will adapt to the LTC setting in a more timely and satisfying manner. Figures 3 and 4 support the use of the OBCHI-MV. In Figure 3, on average, participants increased the total time spent engaged in social and isolated leisure activities and obligatory and discretionary activities from pre to post-test. Social participation and activity engagement were a focus for this study. Social participation increased by 32% and total activity time engagement increased by 25% from pre- to post- test. Nine of ten participants noted, “getting to know

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other residents who could converse at their cognitive level” as being the number one benefit of having participated in the study.

Figure 4 supports the use of the OBCHI-MV as well. Ninety percent of participants reported thinking about military culture and leisure activities more since participating in the study. Participants reported enjoying sessions most that centered on military-related topics. One participant suggested spending more time discussing military experiences as a possible improvement to the intervention. Four participants noted the group sessions made them realize that they were all connected in the past, present and future due to military service to their country.

Eight of ten participants stated they could not participate in leisure activities of choice due to physical disability. However, with occupational therapy-provided adaptations and modifications to activities such as basketball, horseshoes, bowling, cards, etc. the participants were successful in engaging in all of these leisure activities. Three of ten participants noted that being able to participate in outdoor activities again was the highlight to participating in the study. The mean score of the SF-12 (Physical

Component) showed a moderate positive change from pre-to post-test, meaning the participants felt healthier following the intervention. It’s possible that adaptations to facilitate successful participation in leisure activities of choice may have influenced this change score.

Conversely, three of eleven participants scored lower on the Geriatric Depression

Scale post-intervention. The primary researcher conducted a follow up interview with

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each of these participants. One participant reported feeling sad because the intervention facilitated memories of his wife who had passed away and he missed her. The other two participants stated they had enjoyed the groups and were disappointed they were ending.

In addition, the intervention reminded the participants of the independent, meaningful lives they had once lead. One participant stated, “Now I have nothing meaningful to do. I am no good to anyone.” Feelings like these may explain the SF-12 (MCP) and the SCES-

Independence scores, which were higher at pre-test than at post-test.

Limitations

This study has limitations including the small sample size and lack of a control group. Another limitation may have been the homogeneity of gender amongst the participants. However, there were fewer women in military service during WW II, Korea and Vietnam and the facility used for the study houses less than 5% of women who are veterans. Another limitation may have been the age span of the participants. The youngest participant was 60 years old and the oldest participant was 92 years old. 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. The intervention reminded the participants of life roles and activities in which they are no longer able to engage.

This caused some discomfort for the participants as the study ended. Five of the eleven

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participants inquired about continuing the sessions on a smaller, less structured scale.

Unfortunately, the facility resources did not exist to continue with group sessions at that time.

Conclusion

Catherine Trombley said it best in her 1995 Elenor Clark Slagle Lecture

(1995) when she stated:

Occupation as end is not only purposeful, but meaningful. It is the performance of

the tasks or activities that the person sees as important. Only meaningful activity

becomes habit. Meaningfulness of occupation is based on a person’s values that

emerge from family and cultural experiences.

When a veteran transitions to long-term care, he disassociates with life roles and responsibilities he once had, (Katz, 2012). He is no longer an active duty soldier, a husband, pet owner, active Elks Member or church member. Katz, (2012) notes it is important for the veteran’s health and wellbeing to remain engaged in life roles. Long- term care facilities have numerous roles and responsibilities to facilitate veteran engagement in meaningful activities. Long-term care staff including nursing, social workers, activity and therapy departments must recognize how vital it is for residents to perform meaningful activities that give back to the facility and the community. More importantly, facility staff must facilitate opportunities for veterans to continue to serve others, just as they once served their country.

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CHAPTER VI

DISCUSSION

Introduction

This chapter provides a synthesis of the findings of studies one through three. It begins with an overview of the impact relocating to long-term care (LTC) has on veterans. Next, the chapter discussed the benefits of using the Occupation-based,

Cultural Heritage Intervention-Military Version (OBCHI-MV) in the LTC setting. The

Occupational Adaptation (OA) Theory provides the theoretical foundation for the

OBCHI-MV and as such, a visual model of the OBCHI-MV is introduced in this chapter.

The model is accompanied by a detailed description explaining how the OA Theory supports the use of the OBCHI-MV. This chapter also includes: a discussion on authentic occupational therapy, implications for occupational therapy practice, limitations and lessons learned.

Veterans are unique in the way they mentally and physically age; consistent routines and habits often become important to the health and wellbeing of aging veterans,

(Katz, 2012). As such, transitioning to long-term care, where established routines are disrupted and the environment is unfamiliar, can cause stress for the newly admitted veteran, (Katz). If the veteran does not assimilate into the social and physical contexts of the LTC setting, eventually, his or her health could deteriorate, (Katz).

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The LTC facility staff has the ability to ensure that veterans transition effectively to the new setting. By implementing the OBCHI-MV, a protocol-driven intervention that incorporates specific cultural heritage characteristics of recently admitted veterans, staff will learn to understand and appreciate military culture, a unifying factor that connects military personnel of all ages. The OBCHI-MV has the potential to increase adaptation of veterans to long-term care, meaning veterans may experience improved quality of life, social participation and activity engagement.

OBCHI-MV and Adaptation

Figure 3 unifies the findings of the three studies and is based on the Occupational

Adaptation Theory, (Schultz & Schkade, 1997). The veteran possesses person factors that are unique to him such as: life experiences, cultural heritage, ethnicity, spirituality, health and social support factors, which will influence how he will adjust to the LTC setting.

Similarly, the LTC setting is comprised of both dynamic and static environmental factors that may facilitate or impede veteran adaptation. Dynamic aspects of the facility include staff may or may not understand or appreciate military culture, or have the education or experience to facilitate resident personal growth. The static factors of the facility environment are the structure of the building and regulations that dictate care and daily routine of staff and residents/veterans.

The veteran and the LTC facility can unite or collide when the veteran relocates to the LTC setting. Veterans often must relinquish life roles when they relocate to LTC.

For example, the veteran may have been a pet owner or a caregiver for a grandchild, but

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once he relocates to LTC, he no longer fulfills those meaningful life roles. In addition, deficits in person systems, such as sensorimotor, cognitive or psychosocial, can lead to maladaptive behavior. The OBCHI-MV provides a client-centered tool for staff to use to facilitate the resident’s internal adaptive response modes into action. Adaptive response modes are patterns of responding to environmental cues that an individual develops to overcome a challenge (Schultz & Schkade, 1997). The veteran then begins to explore the new environment and develops new, more mature, adaptive response behaviors, which lead to adaptation, as measured by improved quality of life, activity engagement and social participation.

Occupational Adaptation and the OBCHI-MV

In the context of the Occupational Adaptation Theory, Schultz and Schkade,

(1997), discuss how maladaptation occurs when patients experience an inability to engage in meaningful roles due to environmental challenges and/or deficits in persons systems. Person systems are defined as being: sensorimotor, cognitive and psychosocial factors, which are innate to the individual, (Schultz and Schkade). When veterans transition to a LTC facility, environmental limitations of the facility and deficits in person systems may prevent the veteran from engaging in meaningful roles and activities.

Veterans leave their homes, family and friends and most importantly, their daily routines to move to LTC. The sense of loss and disorientation may be overwhelming. Veterans need to re-establish roles and routines in their new environment in order to meet the challenges of a new ‘home’ and adapt to the unfamiliar context.

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Success, as defined by the Occupational Adaptation Theory, is the ability to identify self-generated solutions, evaluate the result, and experience the increase in sense of mastery that drives the urge to engage in challenging experiences, (Schultz and Schkade, 1997). The

OBCHI-MV facilitates veteran adaptive responses yielding an increased sense of relative mastery, i.e. activities or roles that become efficient, effective and satisfying to the veteran and to others. The strength of the OBCHI-MV can be explained by the Occupational Adaptation

Theory in that it promotes the veteran’s ability to generalize the adaptive process to novel challenges, situations and settings that will present as they engage in the daily course of life roles/tasks within the LTC setting. In other words, the OBCHI-MV empowers the veteran to feel competent in activities and roles within LTC, which leads to increased social participation, activity engagement and overall quality of life.

Figure 5: The Occupation-Based Cultural Heritage Intervention-Military Version (OBCHI-MV) Model

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Authentic Occupational Therapy

Elizabeth Yerxa discussed authentic occupational therapy in her 1966 Eleanor

Clark Slagle Lecture. She stated there are four main purposes of authentic occupational therapy: choice, self-initiated purposeful activity, reality orientation, and perception. The

OBCHI-MV protocol manual embeds Yerxa’s four purposes of occupational therapy into scripted group sessions. Choice is exemplified by the veterans’ preferences that are captured via an interview prior to the initiation of the group. Specific food, music and other veteran preferences are incorporated into the sessions to increase comfort and connectedness with the facility. Self-initiated activity is encouraged by engagement in the specific session activity allowing for varying levels of veteran participation. Each session has a purpose and set structure. For example, in session two, veterans create a care package for a veteran in a local homeless shelter.

Yerxa, (1967), describes reality orientation as, “the patient experiences the reality of his physical environment and his capacity to function within it,” meaning one’s reality of the environment and his or her ability to act within it is unique. The OBCHI-MV suggests creating a home-like setting for the group settings. Through participation in group-sessions, veterans become more comfortable in the physical and social contexts of the environment. They also gain a renewed sense of competence, (White, 1971), as activities are modified to optimize function and success. Finally, the OBCHI-MV empowers the group facilitator to shape the perception of the newly admitted veteran.

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The veteran may initially view the facility as being cold and sterile and the staff to be overworked and impatient. However, as the group sessions progress and the veteran becomes more familiar with the facilitator and the other residents, he/she comes to view the facility in a positive manner.

Implications for Occupational Therapy Practice

This study affords a rich variety of implications for occupational therapy practitioners. Long-term care settings are often impoverished environments for patients,

(Wilcock, 1998). Occupational therapists possess the theoretical understanding to educate

CEOs, building planners, administrators and facility staff on the impact environmental surroundings can have on the health and wellbeing of veterans. Facilitating veteran rapport and optimal outcomes are contingent on therapists becoming familiar and comfortable with military culture. Most importantly, occupational therapists understand person and environment factors ensuring aging veterans have to opportunity to “do, be and become,” (Wilcock, 1998). Wilcock described doing as innate and necessary to human existence. Human beings must be able to “do” not only what is expected, but also to perform leisure-time activities. “Being” is the balance between doing and reflecting.

It is satisfaction with the roles one currently fulfills, such as father, soldier, etc. Wilcock,

(1998), suggests that “becoming” is the patient’s aspiration or hope for who he or she would like to be. Veterans who transition to LTC often lose hope of obtaining future personal growth, (Katz, 2012).

Veterans who transition to long-term-care may be unable to “do” due to physical

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or cognitive deficits and environmental constraints. They are unable to “be” who they once were. They are unable to fulfill the role as pet owner, husband, church member, etc., as a result, they lose hope of “becoming,” who they aspire to be.

Occupational therapists, more than any other profession, understands the connection between health and “doing, being and becoming.” This researcher challenges occupational therapists to strive to practice in an authentic manner, (Yerxa, 1968).

Orchestrate harmony between the environmental and person factors of veterans entering

LTC to ensure “doing, being and becoming,” (Wilcock), become a reality.

Additional implications for occupational therapy include:

1. Ensuring therapeutic programming incorporates patient choice

2. Utilizing outdoor space as a therapeutic environment

3. Educating long-term caregivers about the importance of offering patients

choices and control in daily routine, as often as possible

4. Advocating for a home-like environment for patients in LTC

5. Utilizing the OBCHI-MV with veterans transitioning to LTC. Therapeutic

goals can be incorporated into sessions and as long as there is a therapist or

assistant per patient the session will be billable under Medicare.

6. Facilitating social participation, meaningful activities and resident-specific

cultural heritage aspects into therapy sessions.

7. Becoming familiar with military culture and the impact is has on veterans.

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8. When working with veterans use military history, culture and comradery as a

therapeutic tool to ensure veterans feel understood and motivated to reach their

maximum possible potential.

9. Educating LTC staff on the impact person and environment factors have on the

health and wellbeing of veterans/residents and acting as an advocate/consultant

for LTC facilities in understanding the value of the OBCHI-MV and educating

staff on how to implement it.

10. Critically assessing LTC for veterans and advocate for research and changes

as needed

11. Reviewing the work of foundational authors of the profession (i.e. Yerxa,

Reilly) and provide occupational therapy services that treat the mind, body and

soul of patients.

Limitations/Lessons Learned

The limitations for each study are annotated at the conclusion of each chapter.

However, the primary limitation is the small sample size and the lack of a control group.

The sample was recruited from one facility, which could have affected the reliability of findings. The age span of participants was from sixty to ninety-two years, which may have been a confounding variable. The military experiences of a WWII Veteran are much different than that of a Vietnam Veteran, (Katz, 2012). The research design may have been stronger if the participants were limited to a narrower age range, such as 80 to 95

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years. Three of the participants were recruited within one week of admission into the building. Five participants had been a resident in the LTC facility for approximately six months and three participants has been in the facility for one year. The differences in the amount of time could certainly have affected the outcome results.

The positive outcomes of the study may have been attributed to the intervention itself and/or the environment (intervention setting). The primary researcher intended the intervention setting to be an inclusive part of the intervention. However, it may be worthwhile to conduct a study measuring the impact of the environmental setting on the outcomes using an intervention and a control group. The control group could be held in the facility conference room and the intervention group would be held in the gazebo. The intervention would be controlled for consistency. The findings would isolate the impact the environment has on positive outcomes of the intervention.

In addition, it was difficult to separate military culture from cultural heritage. The primary researcher chose to define military culture as military experiences that shape one’s worldview. Cultural heritage was defined as family traditions and life experiences, excluding military experiences, that shape one’s preferences and behavior. However, military culture and cultural heritage are closely related and overlap in some cases. For example, one participant discussed his affinity for Germany. He was stationed there while he was in the military, but his mother was also German. In this case, the participant’s positive feelings about Germany were associated with both his military experiences and cultural heritage.

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Directions for Future Research

Findings from this study support the belief that veterans can benefit from a client- centered, military-focused approach using meaningful activities in a social, home-like setting to facilitate a sense of well-being and quality of life. The OBCHI-MV provides a tool that can be used with standardized assessments to measure adaptation of veterans to long-term care. In addition, the OBCHI-MV can be used by facility staff, such as social workers, activities departments and therapy departments to facilitate a common understanding of military culture amongst residents and caregivers.

Future research is needed to determine veteran benefit when staff members gain an improved understanding of military culture through the use of the OBCHI-MV. In addition, the OBCHI-MV should be implemented in a study containing a larger sample size in a variety of locations in order for findings to be generalizable to the veteran population as a whole. The long-term effects (six months to two years post intervention) of the OBCHI-MV should be researched.

The OBCHI-MV may be a viable tool for wounded warriors who are transitioning from the military to civilian sector when used in conjunction with the LTC veteran population. The younger and older veterans could be a valuable support system to one and another. Co-occupation, the sharing of a social relationship built on cultural understanding between veterans and staff members should be further examined. Co- occupation is defined as; active involvement of two or more individuals in an interrelated, sociocultural activity (Kirchen, 2013). The staff member is educating the

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veteran about the facility and the veteran is enlightening the staff member about military culture and his personal cultural heritage. Through the co-occupation process, greater satisfaction of both veteran and staff member with in the facility can occur. Finally, as previously mentioned, further research is warranted that will isolate the environmental impact and military culture in relation to intervention outcomes.

The intervention sessions should be videotaped to capture the process and participant impact of the intervention. This researcher had difficulty capturing the true impact of the intervention via words and photos. A video recording can provide a more comprehensive evidence of the effectiveness of the intervention. A pre and post- intervention participant focus group may have been helpful in order to capture participant feedback about the value of the intervention, the impact of the environment on the intervention and suggestions for intervention improvement.

Summary

The research question for study one was: What person and environment factors emerge when veterans offer their perspectives about adaptation to long-term care? The research question for study two was: Based upon the perspectives of veterans on adaptation to long-term care, what are the essential components of an intervention protocol? Finally, the research question for study three was: Does the intervention improve the participants’ QOL, social participation and activity engagement?

The participant interviews clearly revealed the person and environment factors that veterans value when transitioning to long-term-care. A protocol manual entitled,

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Occupation-based Cultural Heritage Interview-Military Version (OBCHI-MV) was designed based on participant-identified topics. The manual incorporated music, food, leisure activities, etc. to meet the specific needs of the participants. The protocol was used to facilitate a six-session group intervention. 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.

The veteran population residing in long-term care settings is expected to increase substantially over the next twenty years, (Katz, 2012). Based on the results of this study, veterans feel as if they have no choice or control over their lives once they transition to

LTC. Facility staff members, who do not understand or appreciate military culture, frustrate veterans, and veteran ability to “do, be or become,” is compromised, (Wilcock,

1998). The OBCHI-MV provides a protocol-driven, military culture infused intervention that offers veterans choices, increases staff understanding of military culture and has the potential to increase social participation, activity engagement and quality of life for newly admitted veterans to long-term care.

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APPENDIX A

Military Culture and Lifestyle Interview for Long-term Care

128

Military Culture and Lifestyle Interview for Long-term Care

Past Military History 1. Tell me what was your role in the military? 2. What was the timeframe that you served, i.e. what years? 3. How do you think your military experience has shaped who you are today? 4. Please describe the benefits and challenges of being in the military? 5. If you could go back in time and do it all over again, would you still join the military? And for what reasons? And if not, explain how that is.

Family and the Military 6. How did the military lifestyle affect your family? 7. What did you do to make yourself comfortable i.e. feel at home when you were deployed or continually moving? 8. How did the military affect holidays for you?

Personal Self 9. How did your military experience affect your sense of spirituality? 10. The military provides exposure to different countries, food and culture. How do you think military experience affected your view of diversity/differences in others? Occupations 11. How did the military influence what you did or do for leisure/fun? 12. Were you able to use the skills you learned in the military once you were discharged? Describe how that was.

Current Life 13. How has your military experience helped or hindered your transition to this facility? 14. What would help you to feel more comfortable in this environment? 15. Is there anything else you want to add that might help me better understand how your experience in the military has influenced you in the past or present?

129

APPENDIX B

Life Narrative/Cultural Heritage Interview Guide Revised

130

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

131

! If#at#any#time#during#the#discussion#you#want#to#stop#participating,#you#may#do# so.##You#are#under#no#obligation#to#continue#in#this#discussion#for#any#reason.## This#will#not#be#a#simple#matter#of#me#asking#you#questions.##Rather,#in#this# discussion,#you#are#free#to#share#your#stories#and#memories#of#your#life,# traditions#and#culture.## # Review!key!question:!!With!the!exception!of!the!section!titled!Daily&Life&in&Current&Setting,!the! prompts!below!each!question!do¬!have!to!be!asked!in!all!interviews.!They!are!there!to!use!if!the!! participant!does!not!respond!to!the!question!at!all.!!Additional!prompts!may!include:! ! Tell!me!more!about!that.! How!did!you!feel!about!that?! In!what!way?! What!was!it!like?! Can!you!tell!me!more?! Can!you!give!me!an!example?! !

132

APPENDIX C

SCES Personal Growth Questions

133

! SCES!Personal!Growth!Questions! ! Independence:!!17,!24,!31,!38,!45,!59![scored!in!YES!direction]! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!3,!10,!52![scored!in!NO!direction]! ! SelfIExploration:!!11,!25,!39,!46,!53![scored!in!YES!direction! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!4,!18,!32,!60![scored!in!NO!direction]!

1. Do!residents!usually!depend!on!the!staff!to!set!up!activities!for!them?! Yes! No!

2. Are!residents!careful!about!what!they!say!to!each!other?! Yes! No!

3. Do!residents!usually!wait!for!staff!to!suggest!an!idea!or!activity?! Yes! No!

4. !Are!personal!problems!openly!talked!about?! Yes! No!

5. Are!residents!taught!how!to!deal!with!practical!problems?! Yes! No!

6. Do!residents!tend!to!hide!their!feelings!from!one!another?! Yes! No!

7. Are!many!new!skills!taught!here?! Yes! No!

8. Do!residents!talk!a!lot!about!their!fears?! Yes! No!

9. Are!residents!learning!to!do!more!things!on!their!own?! Yes! No!

10. Is!it!hard!to!tell!how!the!residents!are!feeling?! Yes! No!

11. Are!the!residents!strongly!encouraged!to!make!their!own!decisions?! Yes! No!

12. Do!residents!talk!a!lot!about!their!past!dreams!and!ambitions?! Yes! No!

13. Do!residents!sometimes!take!charge!of!activities?! Yes! No!

14. Do!residents!ever!talk!about!illness!and!death?! Yes! No!

15. Do!residents!care!more!about!the!past!than!the!future?! Yes! No!

16. Do!residents!talk!about!their!money!problems?! Yes! No!

17. ! Yes! No!

18. Do!residents!keep!their!personal!problems!to!themselves?! Yes! No!

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APPENDIX D

SF-12

135

136

137

APPENDIX E

Quality of Life Index-Nursing Home Version

138

139

140

141

142

APPENDIX F

Short Portable Memory Status Questionnaire (SPMSQ)

143

Date ______

Participant ID ______

Interviewer Initials ______

Question Response Score 1. What are the date, month, and year? 2. What is the day of the week? 3. What is the name of this place? 4. What is your phone number? 5. How old are you? 6. When were you born? 7. Who is the current president? 8. Who was the president before him? 9. What was your mother's maiden name? 10. Can you count backward from 20 by 3's?

144

APPENDIX G

Yesterday Interview (YI)

145

146

APPENDIX H

Geriatric Depression Scale (GDS)

147

148

APPENDIX I

Occupation-based Cultural Heritage Intervention-Military Version

(OBCHI-MV)

Protocol Manual

149

Adapted from the Occupation-based Cultural Heritage Intervention

Protocol Manual (2011) with Permission from Dr. Gayle Hersch

Protocol Manual Occupation-Based Cultural Heritage Intervention-Military Version

OBCHI-MV

ADAPTATION OF VETERANS TO LONG-TERM CARE: THE IMPACT OF MILITARY CULTURE

Twylla M. Kirchen

2013

150

Page

Foreword 3

Background and Significance 4

Intervention Research Methodology 4

Theoretical Bases for Group Intervention 6

References 8

Facilitation of Groups 9

Responsibilities for Group Facilitators 12

OBCHI-MV Administration (Non-Research) 13

Documentation 14

OBCHI-MV (Occupation-Based Cultural Heritage Intervention- 16 Military Version) Generic Protocol Session Plan 1: Introduction and My Family 18

Session Plan 2: Cultural Heritage: Home 21

Session Plan 3: Spirituality 24

Session Plan 4: Work: Military Occupations 26

Session Plan 5: Leisure 29

Session Plan 6: Food and Music/Wrap Up 32 Afterward 35 Appendix A: Essays to My Family 36 Appendix B: Military Trivia Questions 45

Appendix C: Military Culture and Lifestyle 53 Interview for Long-term Care-Interview Guide Appendix D: Participant Feedback Form 54

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I. Foreword

This research study is dedicated to the late Dr. Jean Spencer, Professor, School of Occupational Therapy, Texas Woman University, who spearheaded the idea of adaptation to relocation and the implementation of a cultural heritage intervention for newly admitted residents to long-term care facilities.

In addition, this study is dedicated to the amazing World War II, Korean and Vietnam Veterans who provided countless hours of insight and wisdom with the researchers in order to develop the military version of the Occupation-based, Cultural Heritage Intervention.

Over the past several years, this line of research has included five studies that tracked return of elders to the community following hospitalization in a county hospital district geriatric program. Several patterns of relocation were identified, one of them being admission to a long-term care facility (LTCF). These studies affirmed the importance of both personal and environmental factors in shaping relocation trajectories. They also highlighted the importance of satisfaction with care, engagement in activities, and maintenance of social relationships as important outcomes for most elders.

During the summer of 2005, a pilot study was conducted by 3 graduate occupational therapy students, one of who was a Certified Occupational Therapy Assistant (COTA), under the supervision of the PI. This pilot study allowed the research team to test the data collection instruments for usability with a LTCF population and to examine the feasibility of the cultural intervention. For both objectives, the outcomes were positive. By applying an occupation–based intervention, the residents were able to engage in meaningful activities that emphasized their cultural heritage and social and activity participation.

After three submissions to NIH, the research study entitled “Adaptation to long-term care: Developing and testing a cultural intervention for elders” was successfully awarded a National Institute for Nursing Research two-year grant in September 2007. It is a collaborative grant between School of Occupational Therapy and College of Nursing faculty members. This Protocol Manual is a result of Aims 1 and 2 and will was used for Aim 3, the implementation and testing of the cultural intervention.

Hersch, G., Hutchinson, S., Davidson, H., Wilson, C., Maharaj, T., & Watson, K. B. (2012) conducted the study entitled: Effect of an Occupation-Based Cultural Heritage Intervention in Long-Term Geriatric Care: A Two-Group Control Study, which implemented and tested the intervention. The study suggested that by implementing the Occupation-based Cultural Heritage Intervention (OBCHI) during the relocation period (within 12 months of the resident’s admission), the cultural heritage of each individual in the group would be highlighted to promote the person’s adaptation to the facility. Measurement of the resident’s social participation, activity engagement, and quality of life was used to determine the level of adaptation.

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The method of the study was a quasi-experimental, nonequivalent, control group design. Twenty-nine participants were given pre- and post-tests. Residents in the intervention group received a 4-week, cultural protocol-driven, intervention and were compared to the control group, who participated in groups with typical content such as crafts, etc. The results of the study revealed the effectiveness of a structured, occupation-based, group intervention that improved quality of life for participants. There were no significant differences, however, between the control and intervention groups.

Adaptation of Veterans to Long-term Care: The Impact of Military Culture

I. Purpose

II. Background and Significance

Currently, 43% of veteran men are over the age of 60 (Katz, 2012). In addition, 1.8 million soldiers have deployed in combat operations in Iraq and Afghanistan since 2003, some as many as five times. Thousands of younger veterans will require specialized care as they age, and approximately 30% will eventually reside in skilled nursing facilities after age sixty-five (Sorrell & Durham, 2011).

Sorrell & Durham (2011) state the Veteran Affair’s Medical Center’s long-term care facilities cannot meet overwhelming current demands and provide support for veterans with cognitive and physical deficits, who can no longer be cared for at home. They note it is imperative that immediate measures be taken to strengthen resources for research, manpower, and training to accommodate the relocation of aging veterans from home to long-term care.

Veteran’s Affairs Medical Center-Skilled Nursing Facilities, state-funded veteran nursing homes, and civilian-based skilled nursing facilities that provide care to veterans across the United States employ thousands of occupational therapists. Nevertheless, 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 a long-term care settings, does not exist.

III. Intervention Research Methodology

The research team obtained participant informed consent, screened, interviewed, coded interviews, identified themes and developed this protocol-driven intervention based on

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the emergent themes. The participant interviews revealed specific person and environment factors veterans value when transitioning to long-term-care. This protocol was designed based on these participant-identified topics. This manual incorporates music, food, leisure activities, etc. to meet the specific needs of the participants and was used to facilitate the six-session group intervention.

Figure 2 illustrates the Occupation-Based Cultural Heritage Intervention Model-Military Version (OBCHI-MV) and the adaptation outcomes of social participation, activity engagement and quality of life.

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It was the intent of this study to explore military culture and the occupation-based cultural intervention approach with veterans in a residential setting. The basic premise for the cultural group intervention is that an individual’s culture empowers the person with meaningful rituals and beliefs, which can be expressed and shared with others in a supportive social system. Engaging residents in small group interaction and meaningful occupations based on their cultural traditions can foster a sense of connection with other group members.

Hypothesis: LTC veterans, 60 years of age and older, who participate in an occupation- based cultural heritage intervention would report significantly higher measures of adaptation following the implementation of the OBCHI-MV.

1. The Occupation-Based Cultural Heritage Intervention-Military Version (OBCHI- MV) was tested using a quasi-experimental design. A quasi-experimental design involved the use of a nonequivalent pretest/posttest control group design.

154

2. There were 2 intervention groups who received the OBCHI-MV.

3. Groups were selected from state funded veteran’s home. The site was the same one used for the qualitative interviews that served as the basis for developing the OBCHI-MV. There were a total of eleven participants at the site.

4. There were 5 participants in the first group and 6 participants in the second group. See study for the participant demographics.

5. To be eligible to participate in the intervention or control group, individuals were 60 or older, have lived in the LTCF 12 months or less and have passed a cognitive screen.

6. Intervention groups met twice weekly for 45 minutes for three weeks.

7. An assigned graduate Research Assistant administered pretest and posttest instruments to the participants.

8. Participants received a stipend after completing enrollment questionnaires, attending six group sessions, and completing the study.

IV. Theoretical Bases for the Group Intervention

Because the occupation-based, cultural intervention-military version was conducted in a group setting, it is important to examine some frames of reference, assumptions, and concepts that guided the process.

A basic definition of a group is: “an aggregation of people who share a common purpose which can be attained only by group members interacting and working together” (Mosey, 1973, p. 45). Research in the following areas has been considered in the design of the groups that will be conducted, and implications for the occupation-based, cultural groups include:

1. Group dynamics concern the dynamic interaction and the interrelationships between members of the group. From these interactions, members derive multiple types of support and feedback. These dynamics can support growth in individuals, as well as opportunity to meet task, emotional, and social needs. As the group members grow more comfortable with the group, there will be an increased sense of “group” identity and resultant self-direction (Schwartzberg, Howe, & Barnes, 2008). This identity can lead to the group members giving themselves a name that means the group is unique and membership in the group is valuable.

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2. The concept of effectance motivation suggests that in a group setting an individual is motivated to engage in interactions and transactions that can result in a sense of competency (White, 1959). If the occupations and environment match the individual’s level of comfort, explorations of new ways of doing things can result in an increased feeling of efficacy. Although it is assumed that this motivation is innate, sometimes an individual, when met with too great a challenge or when personal meaning is absent, can lose the belief in the expectation of efficacy and this can lead to unwillingness to try new activities.

3. The needs hierarchy addresses a set of basic human health needs that must be met for the person to experience a sense of well-being in all areas—physical, psychological, and social, as described by Maslow (1970). Thus, the group member must experience a sense of physiological wellbeing, a sense of security, and comfort and support in the group before being able to engage in the group task and to achieve possible growth and pleasure in the occupation at hand.

4. Purposeful, occupation-based cultural activities are those that have meaning for the individual, and lead toward goal-oriented behavior. There must be a match between the individual's skills and opportunities for action in the environment (Schwartzberg, Howe, & Barnes, 2008). An ideal match between intrinsic rewards and motivation can lead to an “optimal experience.” This is described by Csikszentmihalyi (1990) as a “flow state,” in which “concentration is so intense that there is no attention left to think about anything irrelevant or to worry about problems” (p. 17). This flow state is an ideal, but it is one the group members should be able to expect at least some of the time.

5. “Adaptation through occupation….means the organization and management of occupational activities and tasks in a manner that meets the goal of achieving maximum…..actualization or satisfaction and accomplishment” (Reed, 1984, p. 495). This supports the expectation that engaging in meaningful occupationally- based cultural activities in the group setting can lead to an increase in adaptive responses that will extend beyond the group activity itself. This is a premise underlying the plan for this group series.

V. Findings/Results

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 a trend towards clinical significance via the Quality of Life Index (Total and Subtests) from pretest to posttest, however change from pre-test to post-test was not statistically significant for any of the measures (all ps > .05). 156

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.

The unifying element for group cohesion was military culture. Ninety-eight percent of participants reported thinking about military culture more after participating in the study and 96% of participants thought more about leisure activities after engaging in the group sessions. Participants reported most enjoying sessions that centered on military-related topics. One participant suggested spending more time discussing military experiences as a possible improvement to the intervention. Four participants noted the group sessions made them realize that they were all connected in the past, present and future due to military service to their country.

Nine of eleven participants stated they could not participate in leisure activities of choice due to physical disability. However, with occupational therapy-provided adaptations and modifications to activities such as; basketball, horseshoes, bowling, cards, etc., the participants were successful in engaging in all of these leisure activities. Three of eleven participants mentioned being able to participate in outdoor activities again as their highlight to participating in the study. The mean score of the SF-12 (Physical Component) showed a moderate positive change from pre-to post-test, meaning the participants felt healthier following the intervention. Adaptations to facilitate successful participation in leisure activities of choice, may have facilitated this change score.

This study was completed by the primary researcher, under the mentorship of Dr. Gayle Hersch, as partial requirement for the completion of Texas Woman’s University, PhD Dissertation in Occupational Therapy. The study focuses on the military cultural aspect of adaptation of veterans to long-term care. Grant funding for the original research study was awarded for 2 years, beginning September 2007 and ending May 2009, by NIH – NINR. Grant team members included: Gayle Hersch, PhD, OTR, Principal Investigator; Shirley Hutchinson, DrPH, RN, Co-Principal Investigator; Beth Mastel-Smith, PhD, RN, Co-Investigator; and Harriett Davidson, MA, OTR, Co-Investigator. However, the primary researcher and Dr. Gayle Hersch funded this study in order to obtain degree completion.

V. References

1. Csikszentmihalyi, M. (1990). Flow: The psychology of optimal experience. NY: Harper Collins. 2. 3. 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

157

Therapy, 66(2), 224-232. doi: 10.5014/ajot.2012.002394

4. 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.

5. Katz, I. R. (2012). Geriatric psychiatry in the department of veteran’s affairs: Serving the needs of aged and aging veterans. The American Journal of Geriatric Psychiatry, 20(3), 195-198. doi: 10.1097/JGP.0b013e3182435f00

6. Maslow, A. H. (1970). Motivation and personality (2nd ed.). NY: Harper & Row.

7. Mosey, A. C. (1973). Meeting health needs. American Journal of Occupational Therapy, 27, 14-17.

8. Reed, K. L. (1984). Models of practice in occupational therapy. Baltimore: Williams & Wilkins.

9. Schwartzberg, S. L., Howe, M. C., & Barnes, M. A. (2008). Groups: Applying the functional group model. Phila: F. A. Davis.

10. 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

11. White, R. W. (1959). Motivation reconsidered: The concept of competence. The Psychological Review, 271-274.

12. Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.) NY: Basic Books.

VI. Facilitation of Groups

Group Setting

The environment can significantly affect the comfort level of residents. The group setting should be comfortable and provide a home-like atmosphere. A gazebo with plants, flowers, pillows, fans etc. provides an ideal location. See below. However, an indoor environment can be equally inviting. Group facilitators should incorporate seasonal food and drink into the conclusion of the session, play age-appropriate music at the beginning and end of each session and ensure residents are warm or cool enough throughout the session. Veterans tend to enjoy being outside. Using outdoor tables or games can be incorporated into sessions. The group session should provide a multi-

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sensory experience that reminds the veteran of home. It will facilitate a connection to the facility. Suggestions include:

Vision: Choose a location overlooking a garden, incorporate home-like items into the setting, such as battery-lit candles, cut flowers, festive plates, linen napkins and table cloths, add a military influence such as an American Flag, military photos, etc.

Hearing: Play Big Band music, 50’s, etc. music at the beginning and ending of each session. Incorporate resident music selections based on the individual interests of the residents. Ensure background noise and distraction is minimal. It is difficult for older- adults to hear when there are multiple sources of sound.

Smell: Cut fresh flowers, mint, basil, etc., in the winter, use aroma scents, prepare food items such as fried fish, grilled meats, etc. within the vicinity of the group (session # 6).

Touch: Ensure the residents who are ambulatory sit in comfortable seats. Regulate the setting for temperature. Provide cloth napkins. Ensure residents can grasp items in order to participate.

Taste: Each session, offer seasonal fruits and drinks. Ensure all food or drink offered follows dietary restrictions. Favorites for summer include: watermelon, ice cream, pie and water with floating fruit. Session 5 allows residents to select a favorite food to be eaten in session 6. Make every effort to obtain the food and prepare it as directed by the resident. Food is a powerful tool when facilitating comfort and connection of residents. In addition, residents feel special that someone has made an effort to serve their favorite food. Residents enjoy sharing the dish with other residents, which facilitates social participation.

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Photos of outdoor area and gazebo-Participants enjoyed this environment so much, several participants from one group remained for the second session. An indoor area can be converted to a home-like environment as well. See photo below.

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Photos incorporating a multi-sensory environment

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Photo of a conference room converted to a home-like setting Note the fresh-cut flowers, table linens, basket and pillow

Group Design

The following principles about expectations of the groups guided the design of the groups, and are important to keep in mind:

Maximal possible involvement of members through group-centered action by Orienting the group to the design Explaining the procedures to the group Setting up the task or activity Following up Maximal sense of individual and group identity Supporting and genuine caring A “flow” experience Creating an environment that stimulates curiosity and the desire to achieve through opportunities or challenges for action Spontaneous involvement Guiding group toward discussion and action in the present Member support and feedback Pointing out what may be perceived as universal elements, needs, concerns and reactions to group members or the group as a whole Members are never criticized, blamed, or made to feel isolated. Group Stages

Groups that continue over time are said to go through stages as they develop and progress. The following stages of groups have been suggested by Schwartzberg et al. 162

(2008):

1. Formation stage. Some issues that might occur among members during the initial stage are: concern over belonging and acceptance, formation of individual and group goals, dependence on leader, and testing the leader style.

2. Development stage. Some issues that might occur as the group gets to know each other better might be: continuing concern of acceptance or rejection as the group progresses, a struggle between safety and increasing involvement, and possible control and power struggles.

3. Conclusion stage. There may be premature termination of attendance for some members for a variety of reasons, and that must be acknowledged. And for those members who stay the whole eight sessions, there will still be termination. There may be sadness, as well as celebration, that the group is ending.

VI. Responsibilities of Group Facilitators

It is important to remember that residents have medical appointments, therapy, visitors, etc. The groups should be planned at the best time for veterans, but occasionally one of the veterans may miss a group session. The session should continue unless there is only one member.

The facilitator should secure the group setting, by reserving it prior to the session. It is recommended to keep the sessions at the same time and days each week.

The facilitator should notify other key staff that the veteran will be engaging in the groups and provide a copy of the group meeting schedule. This is important to avoid scheduling conflicts.

The facilitator should provide the veteran with a schedule of group times and locations prior to the beginning of the first group session.

The group facilitator should be an employee of the facility or a volunteer who has documented HIPPA and Infection Control training.

Administration Procedures for a Non-research-based Version of the OBCHI-MV Occupation-based Cultural Heritage Intervention-Military Version

1. Recall that the protocols are designed so that the intervention can be delivered in a certain planned way. This may seem in contrast to the client-centered way that therapists are accustomed to deliver interventions. It is important to balance adherence to the protocol and a client-centered approach.

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2. The OBCHI-MV is intended to be used with the Military Culture and Lifestyle Interview for Long-term Care-Interview Guide (Kirchen, 2013). Veterans should be interviewed within the first week of transitioning to the LTC facility. The veteran’s interview responses/preferences can be incorporated into the OBCHI- MV group activities, if possible. For example, if the participant enjoys Big Band music or watermelon, the group sessions could include these participant preferences. The OBCHI-MV requires between three and five participants to commence. Veterans should be invited to participate, but it is the veteran’s right to decline group participation, if he so chooses. The veteran should be informed that he is always welcome to join the next group session, if he changes his mind.

3. Activity and therapy departments, as well as social workers could foreseeably use the OBCHI-MV to facilitate adaptation of veterans to LTC. The total time to complete the interview and group sessions, to include the participant feedback survey, is approximately 8 hours. The protocol manual contains six, forty-five minute sessions. The sessions require time to obtain materials and prepare the group setting. It may require 30 minutes to 1 hour to prepare for each session. It is recommended the group facilitator have additional personnel to support group members. One assistant to two participants is recommended. It is important each veteran feel successful and competent during the sessions. Physical limitations may require adaptations of modifications to maximize function. If a group facilitator is not able to adapt a task to allow for participant success, the rehabilitation department could be consulted, as they may be able to provide adaptive equipment or other helpful suggestions.

4. Measuring Intervention Effectiveness.

Effectiveness of the intervention can be captured with pre and post-intervention standardized measures. Any evidence-based (reliable/valid) assessment for depression, quality of life, resilience over all health or activity engagement/social participation can be used. However, therapists should ensure viable research supports the use of the tool and the tool should be administered pre and post- intervention in a standardized manner.

5. The OBCHI is based on the person and environment factors that contribute to veteran’s transition to long-term care. Implementing the OBCHI-MV within a year of when the veteran enters the facility, allows for the proctors of the OBCHI- MV to capture the resident’s cultural heritage and facilitate military cultural cohesion amongst newly admitted and existing veterans. The power of the intervention lies in it’s potential to ignite the military cultural bond between veterans that creates a sense of unity, belongingness and support. In addition, non- 164

military affiliated staff members who use the OBCHI-MV with veterans, have the benefit of gaining increased knowledge and understanding of military culture. This military cultural awareness will be invaluable in assisting newly admitted veterans with adaptation to long-term care.

6. Administer feedback form during the final group meetings.

Retention

Retention will be addressed through a variety of efforts: 1. Facilitators will make reminder calls or stop by to all participants before each group session stating the day, time, and location of the group session.

2. Facilitators will provide each participant a calendar of group sessions for posting in the participant’s room.

3. Facilitators will arrive at the facility one to one and a half hours before each group meeting, if not an employee of the facility, to assist participants in preparation for and in moving to the meeting place.

4. A record of participation will be kept for each session by the facilitator.

5. Facilitators will follow-up with participants who are absent and document reason for absence.

6. If family members or visiting friends request to attend the group with the participant, the group facilitator should confer with the veteran and if the veteran would like his or her family member to join the session, that should be encouraged.

7. VII. Documentation

1. Veterans will be given the opportunity to provide written feedback about the experience of participating in the cultural heritage intervention or typical activity group during the final meeting.

2. The facilitator will record group attendance and participation.

3. Recruitment, retention, and attrition will be tracked.

4. It is recommended that the group facilitators will keep a log of each group session, noting veteran behaviors and reactions to the group interaction and content.

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Photo of group facilitator, Melissa Kurian. Note her forward-relaxed posture as she engages with residents.

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OBCHI-MV (Occupation-based Cultural Heritage Intervention-Military Version) Generic Protocol

Name of group: OBCHI-MV Time/length of meeting(s): 2x/week for 3 weeks = 6 sessions; 45 min/session = 6 contact hours.

Place: Gazebo in garden area with a table and chairs and space for Wheel chairs. Plants/flowers and flameless candles will be arranged to create a home-like atmosphere. Covered snacks and drinks will be available and background music may be softly played.

Group format: Closed

Statement of rationale: The basic premise for the cultural group intervention is that an individual’s culture empowers the person with meaningful rituals and beliefs which, given the opportunity, can be expressed and shared with others in a supportive social system. By engaging veteran/residents in a small group interaction and meaningful occupations based on their cultural traditions, a sense of connection with other group members can be fostered. By implementing the OBCHI-MV during the relocation period (within 6 months of the resident’s admission), the cultural heritage of each individual in the group will be highlighted to promote the person’s adaptation to the facility. Measurement of the resident’s social participation, activity engagement, and quality of life may be used to determine the level of adaptation.

General group goals: Increase activity engagement, social participation, and quality of life. Rationale for goal selection: The above factors are expected to contribute to one’s adaptation.

Outcome criteria for successful goal attainment in sessions: Criteria for achieving goals will be demonstrated by an increase in scores as measured by 2 tools: Yesterday Interview and QOL Index.

Group composition and criteria for selecting members: 3 to 5 members in a group; criteria include age of 60 years plus, a SPMSQ score of 5 or below, and 12 months or less since admission to facility.

Leadership roles and functions: The role of the leader is facilitator. See Protocol Manual pp. 9- and each session plan for responsibilities.

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Expectations of group members: Members are expected to attend all sessions and be attentive and actively participate in the group program. Attendance will be recorded and the facilitator and GRA will note the process and behaviors of the group members.

Group methods and procedures to be employed: Methods: The group modules were developed from the qualitative phase of the study. Participants were interviewed. Interviews were transcribed and coded. The primary researcher and two graduate assistants ensured coding continued until saturation was reached. Six prevalent themes emerged as being important to most participants. The themes were: family, home, spirituality, military job, leisure, and food /music. The primary researcher and two research assistants incorporated specific participant preferences into the six group sessions that were developed from the overarching themes i.e. all participants stated that they would go to the chaplain if they had a concern. A group session was developed that centered on spirituality and the facility chaplain was incorporated into that session. Another example is several patients mentioned a certain type of music, food or leisure activity they enjoyed, but did not have access to. Those particular interests were embedded in at least one of the group sessions.

The long-term goal for this intervention is for it to be used by activity departments, social workers and/or therapy departments to facilitate adaptation of newly relocated veterans to long-term care settings. As such, the activities must reflect the interests and preferences of the veterans. It is recommended that the long-term care facility interview newly admitted residents and embeds their individual preferences into the intervention.

Techniques: The leader will facilitate active participation of the group members through caring communication and meaningful activities. Each session will follow a session protocol that provides structure to the group process yet allows for flexibility as the situation demands. Modalities: Modalities will include a variety of activities selected for the purpose of each group. [Adapted from Schwartzberg et al., 2008].

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Session Plan Group 1-Introduction, Culture and Family

Name of group: Initial Group – Getting to know you: Sharing your culture and family and understanding others’.

Goals for the group session: Each participant will: 1. Become acquainted with other residents in the group. 2. Explore his/her perceptions of culture with the other members. 3. Discuss Participant Definition of Family 4. Bring family photos to share with the group 5. Complete Essays for My Family 6. Discuss Plans for Group 2

Expectations for group members: 1. Ask for help as needed. 2. Assist others as able. 3. Respect each other’s differences.

Description and rationale for methods: Methods will include an explanation of the purpose of the six group sessions, a discussion of the meaning of culture, and the creation of a family keepsake representative of each member’s cultural heritage. These methods were chosen to involve stimulation of auditory, visual, tactile, and kinesthetic senses. Use of these methods will increase activity participation, social interaction, and appreciation of each other’s cultural heritage.

Description and rationale for leadership role: 1. Model behaviors and provide structure so group members feel safe and comfortable. 2. Monitor any participant who may dominate the group process or who is not participating; provide appropriate feedback, e.g. elicit other’s responses if one person dominates. 3. Modify activity to match the participant’s needs. 4. Assist participants as needed, e.g. verbal cues, hands-on, additional explanations. 5. Set the mood for future sessions.

List material and equipment needed: 1. Copies of “Essays for My Family” (5) (Appendix A) 2. Sample Completed Copy of “Essays for My Family” 3. Envelopes to Seal the Copy of “Essays for My Family” (5) 4. Pens/Pencils (10) 5. Clip Boards (5) 6. Participants will bring Photos of Family Members 7. Facilitator will bring a Photo of a Family Member 8. Cheese and Fruit Tray/Lemon-aide/Paper Cups Napkins and Plates

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9. Name Tags

Session procedures: Time and sequence: Introduction [10 minutes] "Welcome, everyone, to this first in a series of 6 sessions where we will meet and talk about your cultural heritage and what it means to you. Each of you was invited to participate in this group because you expressed an interest in sharing your ideas and time to help veterans feel more connected to facilities like this one. If you recall, you were asked to sign a consent form agreeing to participate in these group sessions twice a week for 3 weeks. In return, each of you will receive $10 and, we hope, receive the benefits of meeting other residents, and participating in the other activities in the facility. So, the purpose of this group is to help you feel more connected to this facility by talking about your own culture and family and hearing about others."

"Is everyone comfortable where you are sitting?"

"First, let’s introduce ourselves. I have nametags for each of you so that way we can remember each other’s name. Take a moment to write your name on your tag. My name is ______and I’ll be your group leader for the next 3 weeks. Let’s go around the table/circle and have each of you to introduce yourself [have everyone to introduce themselves]."

"Now that we have gotten familiar with each other’s names, let me explain some guidelines for these groups: first, whatever we say in the group is to be kept within this room, i.e. we don’t gossip about each other’s background or what one says to others outside this group. Also, it’s important that we don’t interrupt each other while a person is talking, and that we respect each other’s comments. That’s pretty basic stuff but I thought that a reminder would be helpful."

Warm-up [10 minutes] "Now to begin this first group session, let’s describe what we mean by culture…who would like to start? [encourage each member to state what they think culture is; if there is difficulty getting the discussion going, provide a definition, e.g. culture is what we learn as we are growing up about our family’s background, the traditions we share, and the holidays, food, and music we have…it’s being part of a group that gives us an identity, comfort, and security]. "What other things are handed down by families? Do you sometimes see your mother, father, or grandparents in how you think or do things? Is there anything else about culture that you would like to share? For example, what about home remedies? Religious values? Disciplinary practices?”

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“Great. Now, I would like to discuss families. Families are a big part of who we are. How do you define a family? What makes a family? (Discuss these questions for 3 to 5 minutes).

(Add a personal story about a family member and show a picture. See below for an example). “I know some of you have brought pictures of your families to share with us today. I will start first. This is my grandmother Clara. She is important to be because she was my biggest supporter and she believed in me when no one else did. I am certain that I would not be here today, if it had not been for her love and support. Let’s go around the table and have each of you share your photos. You do not have to share a photo if you do not want to.”

Activity: Completing “Essays for My Family” "Now that my grandmother is no longer with me, I absolutely treasure anything that was hers. I keep her Bible by my bed and I particularly enjoy re-reading cards and letters she wrote to me. Today we are going to create something that you can keep or share with your families. It is called, “Essays for My Family” and I promise you, your children and grandchildren will appreciate it so much. You are welcome to write it yourself, if you are able and if not we have an assistant for each of you that will help transcribe your thoughts onto the paper for you.”

“Let’s take 25 minutes to work on this activity.”

Discussion [10 minutes] "Now that we have completed the activity, [hold it up for them to see], let’s each share two things that you wrote about yourself in your essay to your family."

“How do you think family shapes your culture? Why is it important to share facts about your life and views with your family? What did you learn about the cultures of the other group members?

Closure [5 minutes] "Thank you for coming today. It was such fun! I look forward to seeing you on ______at ______here at the gazebo. Next time, we will be talking about your home and what makes a place feel like home. Have a good day and see you soon."

Other information pertinent to this specific session: A GRA will be present to take attendance, assist the leader and members as needed during the activity, and bring and return participants to the group.

Other information pertinent to this specific session This exercise has the possibility for producing discomfort if someone did not have a complete family unit, or does not remember names, etc. It may evoke sadness at the loss of certain family members or a

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hurting or bad experience with family, so the facilitator must be prepared to deal with those reminiscences as well. There is also the possibility for storytelling about each family member. If one person tells stories, all should have opportunity to, but if this occurs, the facilitator must limit the amount of time each person can tell stories.

Participant shares a portrait of his wife he had painted, while in Korea during the Korean War.

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Session Plan 2

Name of group: Cultural Heritage: What is Home?

Goals for the group session: Each participant will: 1. Define home--what it means to him. 2. Share their experiences of important cultural and individual cultural features of a home. 3. Reflect on how they have been able to bring their cultural heritage to relocations in the past. 4. Discuss the facility and what does or does not feel like home. 5. Discuss the Homeless Veteran Population in the Community 6. Cheese and Fruit Tray/Lemon-aide/Paper Cups Napkins and Plates 7. Name Tags

Expectations for group members: 1. Ask for help as needed to complete a care-package for the community-based veteran shelter for homeless veterans. 2. Ask for help as needed to generate a letter to the veterans who reside in the homeless shelter.

Description and rationale for leadership role: 1. Encourage participants’ thinking about past experiences of creating a home and a sense of ability to create those homelike elements wherever one is. 2. Facilitate the task, to help participant think about how they have been able to move to a new setting in the past and make it homelike.

List material and equipment needed: 1. Large cardboard box 2. Contact information for a deployed family member of one of the participants, if not possible the care package will be created for a community homeless veteran shelter 3. Items to be selected by the participants and placed in the box such as: playing cards, a phone card, socks, toiletries, books, a journal, cookies, crackers, jerky, a blanket, a newspaper. 4. Paper

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5. Whiteboard 6. Flip chart and easel and markers 7. Digital camera for taking group picture

Session Procedures: Time and Sequence

Introduction [5 minutes] “Welcome, everyone! It is so good to see you all again. We are gathered for the second session of the Cultural Heritage Group. In the past session we have talked about culture and our family.

Warm-Up [10 minutes] Show pictures (posters) of a variety of home settings: “Here are some pictures of houses that are someone’s home. But a home is more than just a house. Some people say, ‘Home is where the heart is…..’ Some of the people we asked said it’s being with people you care about.”

“Let me ask you what you think of when I say “home?” What does home mean to you?” I’ll write the meanings on this chart so we can remember what we’ve said. (Be prepared to say a few words about what it means to you if there is too long a silence.)

(Allow some time to have people answer this question briefly. Write these answers on a flip chart on an easel.)

“You have said home is (summarize the list). “So how did you or your parents create your home? How do you “make a house a home.” (Allow time for a discussion of how that happens. Prompts: “how was it growing up for you? How was it different when you started a family? How was it different when the children left home? How was it when you moved from one place to another?”

Activity: Generating a Care Package for the Homeless Veteran Shelter [20 minutes] “Remember I showed you some pictures of home (hold them up)? Does this look like home to you (hold up a picture of the mattresses under the bridge in a homeless community)? Well, this is home to “John.” He is a Vietnam Veteran. He was twenty years old when he returned from war. People were not welcoming to John and he couldn’t find a job. He got into drugs and he drank. He married and divorced. He has children somewhere, but he doesn’t remember how old they are or where they live now. It has been over forty years since John came home from Vietnam, but he still remembers it like yesterday…and this was John’s home before he moved into a community shelter. John’s life has been a mess, but he is a veteran and we take care of each other.” “Today we are going to put together a care package for John and the other homeless veterans at the shelter. We are also going to generate a group letter to be included in the care package when it is dropped off at the shelter.”

“On the table are a variety of items that could go into the care package. We are going to

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go around the table and take turn selecting an item for the box. When you choose and item, please tell the group what significance the item will have for a homeless veteran.”

When box is full state, “Great, now let’s work together to generate a heart-felt note to the homeless veterans to be included in the box. You tell me what you would like to say and I will write the letter.”

When the letter is completed, read it back to the group and place it on top of the box of items.

Discussion [15 minutes]

“Let’s talk again about what you did to make each of place you lived a “home.” (Facilitator may need to help make the connection between people and the commonalities and differences in how they make a home.) “It sounds as if home can truly be where the heart is. I know John and the other homeless veterans will be very appreciative of the care package you have created for them today. Your thoughtfulness will certainly give them a little slice of home.”

Closing [5 minutes] “This has given us a chance to think about the rich cultural heritage that each of us brings to this group. It has also given us a chance to think about our idea of what a home is, and how we each have contributed to making a home wherever we are."

"At the last session we talked about making a picture of your group as a way to celebrate these sessions. Are you ready for the photo session?" (Assemble group for picture)

“The next session will focus on military occupations, destinations and history. We will break into 2 teams and play Trivia for prizes.”

“Thank you for coming today and for making this group a time for sharing yourself and your ideas about how culture influences how one makes a home truly a home.”

Other information pertinent to this specific session This exercise has the possibility for producing discomfort, as early in the adaptation process to the LTCF the participant may not be ready to think about the idea of the LTCF as ‘home.’ If the issue emerges of the perceived absence of homelike qualities in the LTCF, the facilitator will need to guide the discussion to positive qualities of the LTCF. Vietnam Veterans in the group may become emotional, as it will bring back uncomfortable memories.

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Photo of items donated by facility staff to support the group session. Items included, non-perishable food, water, personal care items, clothing, a cooler, fly swatter, spray, a first aide kit and zip lock bags, wet ones, etc.

Session Plan 3

Name of group: Spirituality

Goals for the group session: Each participant will: 1. Identify religious or spiritual activities practiced throughout one’s life. 2. Discuss the meaning that religion or spirituality had over the course of one’s life. 3. Meet with the facility chaplain to her about his role and responsibilities, hours of availability and church service options for Sundays and other days of the week. 4. Participate in a group prayer lead by the facility chaplain.

Expectations for group members: 1. Ask for help as needed. 2. Offer help to others during the activity. 3. Participate in prayer topic activity. 4. Interact with and welcome facility chaplain to the group.

Description and rationale for methods: Group discussion will be used to identify participants’ religious or spiritual practices. Listening and singing along with music associated with religion or spiritual practices may help to connect individuals to their spirituality and cultural heritage.

Description and rationale for leadership role: 1. The leader will facilitate the discussion and sing-along to enhance awareness of the variety of spiritual experiences. 2. The facilitator will introduce the facility chaplain to the group.

List material and equipment needed: 1. Flip chart paper

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2. Markers 3. CD player, CD including a variety of religious / church music 4. Prayer Basket/Small Pieces of Paper and Pens/Pencils 5. Snack Trays and Drinks

Session Procedures: Time and Sequence

Introduction: [5 minutes] “People have told us that religion or spirituality has been important to them throughout their lives. Religion or spirituality is a significant part of people’s culture. Religion or spirituality can be expressed or practiced in many different ways depending on one’s beliefs or culture. (Facilitator, ask and write participants’ answers on flip chart paper:) “What type of religious activities did your family participate in when you were young, with your own family, or now?” Activity [10 minutes] “Our facility chaplain will be joining us in a few minutes to talk with you. He is a veteran himself and is dedicated to meeting your spiritual needs within this facility. Before he arrives I would like you to take a moment and think of a special prayer request. It can be a person or situation. You can ask for a prayer for you, yourself if you would like. We are going to write our prayer requests on these small pieces of paper, fold them, and put them in the basket. If you would like, we can assist you with writing down your request, or you can do it yourself if you prefer. Let’s take a few minutes to do this.”

“Great! Now I would like to introduce Chaplain______. He is going to tell you a bit about himself, his responsibilities as Chaplain and what church services are available within this facility. We will end by have Chaplain ______lead us in prayer for us and our prayer requests that are here in the basket.”

(Allow 10 minutes for the chaplain to complete the above-mentioned items.)

Discussion [10 minutes] “Think for a moment about your own spirituality or religious practices, and then let’s discuss: How has spirituality or religion helped you in your life? Can you give a specific example?”

Closure [10 minutes] “This has given us a chance to think about the rich cultural heritage that each of us brings to this moment. It has also given us a chance to meet Chaplain______and learn a bit more about what he does and what spiritual services are offered in the facility. Thank you Chaplain______for joining us today. Next session we will be discussing military and civilian jobs. We have two fun games to play and we look forward to seeing you then.

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Other information pertinent to this specific session The discussion on religion may elicit different views and facilitator may need to manage the tone. Members will have varying abilities to contribute to the discussion of the recalling and valuing the 6 sessions. They may need help in seeing that the group sessions are ending but there is still the possibility to continue their relationships with each other. There is also the possibility that some members will have left the group and that will need to be acknowledged and processed as loss.

The participants identified the Chaplain as the individual they would be most likely to talk to if they had a concern. The facility Chaplain was present for the Spirituality Session. Participants enjoyed asking questions and learning that the Chaplain is a veteran also. Session Plan: Group 4

Name of group: What kind of work did you do? (Military/Civilian Job)

Goals for the group session: Each participant will: 1. Describe what work they did in the military and civilian sectors. 2. Describe what work means to him. 3. Participate in “Pull it out of the Bag” game. 4. Participate in Military Occupations Trivia Game. 5. Discuss participant willingness to engage in being a Wounded Warrior Buddy and/or commit to other jobs such as weeding and watering the garden, spraying for bugs or creating vegetable baskets for the homeless shelter.

Expectations for group members: 1. Ask for help as needed. 2. Offer help to others during the activity. 3. Be open to what others have to say. 4. Share ideas and contribute to the narrative.

Description and rationale for methods: Work is an essential part of our lives and becomes the norm for most of us. No matter what kind of work--paid, volunteer, and/or military, being productive and active in some kind of work task is part of all of our lives. By describing and discussing the meaning and value of work, on a personal level, the worthiness of the person and restoration of a sense of pride in past accomplishments and cultural heritage may be acknowledged.

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Description and rationale for leadership role: 1. Encourage verbal participation from each member. Have them reminisce about past work settings, co-workers, and/or military occupations. 2. Monitor any resident who may dominate the group program or who is not participating and provide appropriate feedback. 3. Ensure that each member has a ‘voice’ and actively participates in the activity.

List material and equipment needed: 1. White board or flip chart with pens. 2. Army duffle bag with the following items: WW II helmet, ammo pouch, LCE, E- Tool, compass, canteen, etc. 3. Music to Trivia Game and CD Player 4. Board with Trivia Questions about military jobs covered and aligned under various military branches 5. Coin for coin toss 6. Basket with personal hygiene items for prizes. 7. Snack tray and Drinks

Session procedures: Time and sequence:

Introduction [5 minutes] “Welcome back, everyone, to the Cultural Heritage group and how is everyone?” “This is the 4th session of our group, and in the first four sessions we talked about what culture, family, home and spirituality.”

“Today we are going to discuss work, specifically what we did in the military. We will relate work and the meaning of work to culture. For example, the work that one does may be a reflection of his or her culture. For example, people from certain cultures may be more likely to work in certain jobs such as the military. Or, work may mean taking care of the family and home, and this is a reflection of cultural values.

“Work is often passed on from one generation to the next as part of a culture—for example, father was a carpenter, so son was a carpenter, or father worked in steel mill, so did son. Also other kinds of skilled labor or professional work.”

Warm-up [20 minutes] Have each person describes what work means to them and write their ideas on the board/paper. “Let’s start by sharing what job you had while you were in the military and what job you had after you were out of the military.” Go around the table and have each group member share.

“Describe what you did? What made it important to you? Did your work require any kind of training or education?

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How long were you in the military?

Activity [20 minutes] “Today we have two military-related activities that you’ll enjoy. The first is-“Name that Item.” I have this lovely duffle bag that I received at Basic Training. We will take turns reaching inside of the bag and pulling out some military-related work item. To get full points, you need to state the name of the item and what it was or is used for. Let’s begin.”

When all of the items are removed from the bag, tally the points from the game and announce the winner. Allow him to select a prize from the basket.

“ Now our second game is a military occupation trivia game. You will be broken into two teams. We will flip a coin and the winner may select a category. The members of the team have 15 seconds to give the final answer. The final scores will be tallied and the winning team will each receive a prize. Let’s begin.”

Discussion [10 minutes] Process the group experience with the members. Summarize the relationship between work and culture. Use examples of what was shared during the group to relate jobs or values to a particular culture.

“Let’s talk about what we discovered about the relationship between work and culture. (Summarize the different kinds of work represented in the group, and people’s comments about their culture. Some of the comments may need to refer to prior sessions and discussions about culture, so the connection can be made.)

Closure [5 minutes] Describe briefly next session’s program on the topic of leisure activities. “The topic for the next session is “leisure” and we will be discussing activities you enjoyed in your childhood, adulthood, during the military and what you do here in this facility. We will participate in a few fun activities that can be easily modified if need be so that everyone can participate.” “Thank you for coming today, and I look forward to seeing you for the next session.”

Other information pertinent to this specific session: A GRA will be present to take attendance, assist the leader and members as needed, and bring and return participants to the group.

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Participant sharing his responsibilities while serving in the U.S. Army

Session Plan: Group 5

Name of group: Leisure to me? What is your favorite pastime?

Goals for the group session: Each participant will: 1. Describe what leisure means to him; derive a common definition to which all group members can relate. 2. Identify a minimum of 2 play activities in which he/she engaged as a child and 2 leisure activities as an adult (during deployment and at home). 3. From a list of possible leisure activities, select two or three that all can agree upon and actively engage in(e.g. table games like playing cards, checkers).

Expectations for group members: 1. Ask for help as needed. 2. Assist others as able. 3. Respect each other’s differences.

Description and rationale for methods: Leisure is a normal part of life and is determined in many ways by one’s culture. By being involved in pleasurable memories of past leisure and play activities, the participants should derive a sense of satisfaction and happiness. The intent of sharing and 181

engaging in such group activities is to facilitate their active participation, social engagement, and cultural identity.

Description and rationale for leadership role: 1. Modify activity to match the participant’s needs. 2. Assist the person with verbal cues or hands on strategies, as appropriate. 3. Encourage verbal and ‘doing’ participation from each member; ensure that each member has a ‘voice’ and actively participates in the activity. 4. Monitor any resident who may dominate the group program and provide appropriate feedback.

List material and equipment needed: 1. White board or flip chart with pens. 2. List of pre-selected activities (table games) from which the group can make a selection (each person will be given a written list of table and card games including checkers, dominoes, Trivia cards, horseshoes, baseball, basketball etc.) 3. Assorted materials of those activities they decide to do. 4. Examples of childhood toys (tops, jacks, jump rope, etc., Army men) 5. Table game supplies: 2 sets of dominoes; 4 decks of playing cards; checkers and board. 6. 2 card holders for one-handed players (in case they are needed)

Session Procedures: Time and sequence: Introduction [5 minutes]

“Welcome. Glad to see everyone. How have you been?”

“This is the 5th of our sessions about Cultural Heritage. In the first 4 sessions, we talked about what culture means, we talked about family, home, military jobs and spirituality. “Today’s activity has to do with the time we have spent in adult leisure activities and childhood play activities. The culture in which we grew up or with which we identify, at least in part, influences what leisure activities we participate. For example, people from one culture may play mah jong while people from another culture may play dominos or bid whist. Today, we will spend some time talking about what ‘leisure’ means to you and what you used to do as a child growing up with your family and friends and then what you have done as an adult with family and friends for ‘fun’. For example, when I was a child, I played ‘dress-up’ (or whatever the group facilitator personally did) and had lots of fun putting on my mom’s old hats and dresses, and as an adult, I like to play the card game, bridge, with my friends.”

Warm-up [15 minutes] Have each person describe what leisure means to them and write their ideas on the board/paper.

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“What does leisure mean to you? I will write your ideas on this paper as you talk about them. What does your family do for fun?”

Have each person identify 2 childhood play activities and 2 adult leisure activities. Write their ideas on the board/paper. Use pictures of these activities to stimulate conversation. “Here are some pictures of leisure activities that you might have played as a child, and some that you might be doing now. Can each of you name two activities from your childhood, and two that you like to do as an adult? I will write them down as you name them.”

Activity [30 minutes] As a group, select an activity from a list of table and card games (dominoes, bid whist, fish, bridge, canasta, checkers) and engage in that activity, in pairs or in small groups, however best to divide the group. “I am passing around a list of table and card games for each of you to look at. Now, I would like you all to select one activity that you would like to play during the next half hour. Now, some of these games are played with two people, some with four, and some can be played with any number of people. So, how would you like to divide up?” (Assist them in relocating for the games, and finding table space as needed, etc.)

Discussion [10 minutes] Process the group experience with the members; relate what activities they did or identified with their cultural heritage.

“Let’s talk about your experience. (Possible probes are): “What was most fun today? What reminded you of your cultural heritage? What memories were triggered about your culture, family and friends?”

Closure [5 minutes] Summarize this session’s activities and then describe briefly next session’s program related to food and music. Remind the group that next week will be the last session. “Today we spent some time talking about the place of play and leisure in our lives. Play and leisure are important activities not only because they help us relax, have fun, and spend time with others, but because they connect us to our cultural heritage.” (Summarize the high points of what games they played, some of the laughter, interaction, etc.)

“For the next session we will be sharing our favorite foods with the group. Please identify 1 type of food you particularly like or that has strong cultural meaning for you.” (Write down each person’s food choice, prior to ending the session) “Thank you for coming!”

Other information pertinent to this specific session:

A GRA will be present to take attendance, assist the leader and members as needed, and bring and return participants to the group. Keep in mind that some residents may view card games negatively due to religious beliefs. Some may have difficulty keeping scores

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or remembering the game rules, and may need assistance. Some may have difficulty holding the cards or game pieces.

Participant playing basketball

Session Plan 6

Name of group: Food and Music

Goals for the group session: Each participant will: 1. Discuss how food influenced their cultural heritage. 2. Discuss favorite foods eaten as a child or on deployments. 3. Identify all locations they have lived on a map of the world and discuss the food from that region. 4. Taste favorite foods and state the connection or relevance of that food to them. 5. Taste foods from foreign countries that host American soldiers, such as Korea, Germany, Italy, etc. 6. Listen to various songs and discuss what the songs have meant to them. 7. Participate in Name That Tune. 8. Discuss conclusion of sessions and complete survey

Expectations for group members: 1. Ask for help as needed. 184

2. Offer help and encouragement to others' activity. 3. Respect comments of others. 4. Participate in food tasting and music games. 5. Discuss Termination of group and say “Goodbye.”

Description and rationale for methods: Methods include food sampling via a Tapas style and a two-team Name that Tune activity. These methods were chosen to involve stimulation of auditory, visual, and taste. Use of these methods will increase activity participation, social interaction, and appreciation of each other’s culture.

Description and rationale for leadership role: 1. Orient group to activities for the session in order to encourage participation. a. Monitor group dynamics to redirect domineering members and to encourage participation of less verbal group members. b. Assist with music game. c. Assist with tasting activity and ensure that snack is compatible with dietary restrictions.

List material and equipment needed: 1. Record Player/35 records. 2. CD player 3. Variety of music from ‘50’s, ‘60’s, ‘70s, and contemporary eras, to include blues, big band, duwop, zydeco, gospel, and country and western 4. Food item identified by participant from previous session 5. Common Foods from Deployable Countries 6. Plates, plastic ware, cups 7. World map with stickers 8. Basket of personal hygiene items/prizes 9.Copies of Participant Evaluation of Cultural Heritage Sessions for GRA to assist participants to fill out.

Session Procedures: Time and Sequence

Introduction [5 min] “Welcome to Session six of our Cultural Heritage sessions. How is everybody today? We are moving along. It’s good to see everybody. Let’s briefly review what we have talked about so far. What did we talk about at Session I? We talked about the meaning of culture and family. What did we talk about during the second session? We talked about home. And what did we talk about during the third session? We talked about military jobs and played trivia. In session four, we met with the Chaplain. In session five, we discussed leisure activities.

Today, in Session six, we will focus on two really fun cultural heritage subjects; food and music! We have a lot to do in this session! When we asked other seniors about these

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topics, a lot of emphasis was placed on good music and tasty traditional foods. So, today, we want you to get involved in two activities about these topics – food and music! The first one is a food activity and the second one is a music activity. Let’s get started!

Activity Cultural Food [15 min] “To help you remember traditional foods that were or are important to you, we are going to identify all the places you have lived by pinpointing them on the map. Then we are going to discuss the food in these places. What are some of the places you have lived.” Place stickers on the map as participants call out places. “Great, now lets talk about food you enjoyed most from all of these places.” Go around the table and give everyone the opportunity to speak. “You certainly have a wide variety of foods you enjoy. We have some of those foods here today. Not only do we have your pre-selected favorite food, we also have foods from around the world. Let’s go ahead and create our plates. You are welcome to take a little bit of everything, if you would like. You do not have to eat something if you do not like it. After we have created our plates, we can go ahead and eat. While we are eating, I would like to go around the table and have each of you share with the group the significance of your food of choice.

Discussion [10 min] “Let’s talk about the food you chose for the group. How did food fit into family life? Did everybody sit down and eat together? What foods were commonly eaten? Who did the cooking? What holiday foods were traditional? What is your ultimate favorite dish? Does the LTCF serve any of your favorite dishes? Is there any other way that you get favorite dishes? Do you have questions for group members? Remember that they have to be compatible with your dietary restrictions.” “Thank you for participating in this activity.” Let’s boogie down! (with dance type music playing in background).

Activity – Name That Tune! [20 min] “We are going to enjoy music from the past and present. We will listen to all kinds of music, because when we asked other seniors about music, a variety of music was mentioned. Jazz, blues, and gospel music were mentioned most often. Rap music was sometimes criticized, but it is a major part of today’s music. Music of various kinds is a part of everyone’s cultural heritage. So, today we will listen to a variety of music and even dance a little. We will respect and appreciate each other’s music.

“As songs are played, try to name that tune or the singer or type of music. You may just blurt it out.” Praise the ones that get the correct name and move on to the next song.(Facilitator will play doo wop music, country and western, blues, and other dance music. “Let’s see some movement such as foot tapping, finger tapping, swaying in chair, and dancing on the floor if you can”. Is there anyone here who wants to show us dance steps, such the zydeco or waltz?” End the session with gospel music.

Closure [10 min] Process the group experience with the participants. Facilitator will ask “What memories

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did these songs bring back? Where were you in your life stage or what were you doing when you first heard some of these songs? Do you get to listen to your favorite music today?” “Do you have questions for other group members?”

“This is our last group session. I hope you have enjoyed our time together and gotten to know each other a bit better. Before you leave, you will have opportunity to give feedback on the Cultural Heritage sessions. It will help us to know your opinion of the groups. Is there anything that any of you would like to say before we conclude our final group session? Please take time to fill out our evaluation forms. It is important that we receive your feedback regarding these group sessions. Thank you for your time and dedication. Before you leave, we have a small gift for each of you. It is a group picture in a frame to remind you of our time together." (GRA will assist the participants in filling out the Participant Evaluation of Cultural Heritage Sessions)

Other information pertinent to this specific session: A GRA will be present to take attendance, assist the leader and group participants as needed, and bring participants to group and return them to their rooms or elsewhere in the LTCF. There may be a lack of respect of certain types of music. Residents may express sadness about the groups ending.

Photo of Session 6-Residents sat family-style to share food and music

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Afterward

The primary researcher of this study would like to thank Dr. Gayle Hersch for her support, dedication and patience in regards to this study. Dr. Hersch was not only willing, but also excited about sharing her work in order to facilitate adaptation of veterans to long-term care settings.

This study would not have been possible without the hard work and superb organizational skills of Rachel Warren, OTS, UNC, Chapel Hill. In addition, Melissa Kurian’s (Graduate Student) insight, enthusiasm and creativity were instrumental to this study.

Thank you to Sue Coppola from UNC, Chapel Hill, for generously granting permission for the use of Essays for My Family.

Rachel Warren, OTS, UNC, Chapel Hill cheers on a participant in the Leisure Group Session

Note: This protocol is to be used in conjunction with the Military Culture and Lifestyle Interview for Long-term Care. See Appendix C. The interview should be used to gather relevant information about newly admitted veterans. Veteran preferences should be incorporated into the activity sessions when possible.

The Military Trivia questions and answers purposefully do not align. Group facilitators are encouraged to become familiar with the answers prior to implementation in a group activity. In addition, facilitators should incorporate military questions related to specific participant military occupations as identified during the interview.

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Essays for My Family*

Author:

Date:

Date of Birth:

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Message to the reader:

Family is what you make of it. For the purposes of this book, my good friends are part of my family.

This book is dedicated to:

People I especially want to read this are:

*Thanks to Thomas E. Hollingsworth, my father-in-law, for your "Essays for my Family", the gift and the idea. S. Coppola, MS, OTR/L, BCG

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The place I was born:

My earliest memories:

What it was like growing up:

Things I did when I was a child:

Important people from my childhood

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How I spent my time as a young adult:

My life as a middle-aged adult:

Things I do now, and why I do them.

Frustrations I have with doing things now:

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What makes my life different from everyone else’s:

My greatest accomplishment or the thing I am most proud of:

The best thing that ever happened in my life:

The worst thing that happened in my life:

The most surprising thing that happened in my life:

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My deepest regret ( that I want to share):

Some favorites:

Book______

Music______

Place______

Pet______

Hero______

Year______

Food______

Saying______

President______

Holiday______

Sport______

Joke______

Other favorites: 194

The most amazing change that occurred during my lifetime:

What I most look forward to:

What I wish I knew when I was younger:

What young people should know about old age:

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Things I want to finish while I am alive:

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People I want to thank:

People I want to forgive:

People I hope will forgive me:

Things I wish to say to specific people:

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If someone were to quote me, remember me or describe me, this is what I want said:

If my life were a book, I would like the last chapter to be:

How I wish to spend the last days of my life:

My hopes for the future:

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Eleanor M. Savko 8/4/13

Military Army Navy Air Force Marines History 5 pt 5 pt 5 pt 5 pt 5 pt What do you call the 10 pt 10 pt 10 pt 10 pt 10 pt soldier who cares for the

15 pt 15 pt 15 pt 15 pt 15 pt wounded on the battlefield? 20 pt 20 pt 20 pt 20 pt 20 pt

25 pt 25 pt 25 pt 25 pt 25 1pt 2

What do you call the What is an Army Sergeant who trains the Medic? new recruits at Basic Training?

3 4

What is a Drill What do you call the Sergeant? ground soldier?

5 6

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Eleanor M. Savko 8/4/13

What do you call the What is an soldier who jumps out Infantryman? of a perfectly good airplane?

7 8

Who is responsible for What is a all the tank and cavalry/ forward reconnaissance paratrooper? operations on the battlefield?

9 10

Who deals with helping What is an Armor to feed and prepare Officer? meals for the personnel in the Navy?

11 12

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Eleanor M. Savko 8/4/13

Who inspects, maintains and repairs aircraft mechanical and electrical What is a cook? armament and ordnance systems, and stows, assembles and loads aviation ammunition? 13 14

Who stands watch as assistants to officers of the What is an Aviation deck and the navigator, Ordnanceman? serves as helmsman, and performs ship control, navigation and bridge watch duties? 15 16

Who operates and maintains guided missile What is a launching systems, gun Quartermaster? mounts and other ordnance equipment, as well as small arms and magazines?

17 18

201

Eleanor M. Savko 8/4/13

Who keeps exterior surfaces of ships in good What is a Gunner’s condition, maintains machinery and equipment Mate? on ships' decks, and handles cargo and operates small boats? 19 20

Who is responsible for What is a flying planes and commanding various Boatswain's Mates? military missions and oversees a flight crew?

21 22

Who ensures that long- awaited letters from What is a Pilot? home reach their final destination?

23 24

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Eleanor M. Savko 8/4/13

Who guides the airplanes in combat and non-combat What is a Postal missions by reading maps specialist? and using radar and other methods to guide the pilot safely to his destination?

25 26

Who performs scheduled inspections, functional What is air traffic checks and preventive controllers? maintenance on tactical aircraft and aircraft- installed equipment?

27 28

Who sets up air traffic What is a crew chief/ control and performs tactical aircraft close air support in maintenance specialist? remote locations?

29 30

203

Eleanor M. Savko 8/4/13

Who sets up and What are Combat operates all radio Controllers? equipment used in a field mission?

31 32

Who performs assigned military law enforcement duties to uphold the What is a field radio criminal justice system and operator? support the commander's security requirements in peacetime and combat 33 operations? 34

Who directs artillery What is military and naval gunfire in police? support of the infantry?

35 36

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Eleanor M. Savko 8/4/13

Who plans and carries out the What is a Field maintenance of Artillery soldier? materials and movement of

37 personnel? 38

Who operates intelligence collection What is a logistics and communications equipment, conducting specialist? collection, analysis, production and

39 dissemination of data? 40

What is the U.S. What is a signals Army's infantry intelligence operator/ version of the M-240 analyst? machine gun often called?

41 42

205

Eleanor M. Savko 8/4/13

What is the largest U.S. What is 240 Bravo? Navy ship?

43 44

What was the code What is an aircraft name of the Second carrier? Battle of Fallujah?

45 46

Who is the only What is Operation President to earn a Phantom Fury? Medal of Honor?

47 48

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Military Culture and Lifestyle Interview for Long-term Care

Past Military History

16. Tell me what was your role in the military? 17. What was the timeframe that you served, i.e. what years? 18. How do you think your military experience has shaped who you are today? 19. Please describe the benefits and challenges of being in the military? 20. If you could go back in time and do it all over again, would you still join the military? And for what reasons? And if not, explain how that is.

Family and the Military 21. How did the military lifestyle affect your family? 22. What did you do to make yourself comfortable i.e. feel at home when you were deployed or continually moving? 23. How did the military affect holidays for you?

Personal Self 24. How did your military experience affect your sense of spirituality? 25. The military provides exposure to different countries, food and culture. How do you think military experience affected your view of diversity/differences in others? Occupations 26. How did the military influence what you did or do for leisure/fun? 27. Were you able to use the skills you learned in the military once you were discharged? Describe how that was.

Current Life 28. How has your military experience helped or hindered your transition to this facility? 29. What would help you to feel more comfortable in this environment? 30. Is there anything else you want to add that might help me better understand how your experience in the military has influenced you in the past or present?

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Participant Feedback Form

Date______

We began these sessions with the expectation that at the end of the six weeks you would:

-Have the opportunity to remember your cultural heritage -Think about what your cultural heritage means to you

We have talked allot about how your military culture has shaped your cultural heritage.

With that in mind, please respond to the following:

1.Since beginning these sessions, I have thought more about food I enjoyed during my life.