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... 1 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2025 Effect of an Educational Presentation to Increase Preemptive ondansetron Administration for Reducing Spinal-Induced Hypotension and Bradycardia Cody Brandes Marian University Leighton School of Nursing, Chair: Dr. Bradley Stelflug, DrAP, MBA, CRNA Signature Committee Member: Date (April 24, 2024) Adrienne Merrick, MSA, CRNA Signature Date (April 24, 2024) ONDANSETRON PRIOR TO SPINAL ANESTHESIA 2 Table of Contents Abstract4 Introduction..5 Background..5 Problem Statement...8 Needs Assessment & Gap Analysis.9 Review of Literature9 Hemodynamic stability..10 Effect of ondansetron on occurrence of SIH..10 Effect of ondansetron on occurrence of bradycardia.11 Effect of ondansetron on need for additional intervention12 Contraindications of current approaches...13 Performance of ondansetron and side-effects of ondansetron...13 Framework.....14 Project Aims & Objectives....15 Project Design & Methods.15 Materials & Tools..17 Pretest & Posttest...17 Educational Presentation17 Retrospective Chart Review & Collection.18 Statistical Analysis.18 Data Analysis ....19 Ethical Considerations...20 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 3 Results....20 Pretest and Posttest Results20 Retrospective Chart Review Results..25 Discussion..26 Pretest & Posttest...26 Retrospective Chart Review..29 Strengths & Weaknesses30 Conclusion.31 References..33 Appendix....40 Appendix A: Johns Hopkins Nursing Evidence-Based Practice Model....40 Appendix B: PRISMA Diagram ...41 Appendix C: Pretest.. 42 Appendix D: Posttest ....43 Appendix E: Educational Presentation .....44 Appendix F: Consent ....52 Appendix G: Literature Review Matrix ....58 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 4 Abstract Background: The utilization of lower extremity total joint arthroplasty (TJA) has increased over time, with over 2.2 million hip and knee arthroplasty procedures performed between 2012 and 2020. These procedures are very painful for patients; therefore, providers may choose to perform a neuraxial anesthesia to block the initiation and conduction of the pain nerve pathway. However, there are side effects from neuraxial anesthesia. Hypotension and bradycardia from neuraxial anesthesia are common side effects and are caused from the blocks ability to elicit the Bezold-Jarisch reflex (BJR). A prophylactic administration of the medication ondansetron (Zofran), can attenuate some side effects of spinal anesthesia. Purpose: This project was developed to educate anesthesiologists and CRNAs that there is a new safe and effective intervention to add to their current practice. To attenuate the side effects from choosing a neuraxial anesthetic for patients undergoing a total knee arthroplasty. Methods: This DNP project collected quantitative data through electronic pretests and posttest. A retrospective chart review was conducted to evaluate if there was an increase in prophylactic administration of ondansetron (Zofran) prior to a spinal anesthetic after participating in an educational presentation. Implementation: Five anesthesia providers at a rural hospital in northern Indiana participated in this project. The providers were given an online pre-test and then once completed there was a link provided with education from a PowerPoint presentation. Following the presentation, a posttest was administered. Additionally, a retrospective chart review was conducted three months before and three months after the educational intervention to determine if a practice change had been made regarding the timing of ondansetron administration. Conclusion: The introduction of an education intervention suggest a generalized improvement in knowledge about prophylactic administration of ondansetron for total knee arthroplasty under a spinal anesthetic, the Bezold-Jarisch reflex, and alternative interventions in pre-test to post-test scores despite not being statistically significant. Additionally a retrospective chart review indicated that before the educational intervention, successful prophylactic administration of ondansetron prior to a spinal anesthetic improved and incorrect administrations decreased posteducational presentation. Keywords: Ondansetron, Spinal, Neuraxial, Spinal induced hypotension, Spinal- induced hypotension Co-loading, Zofran, TJA, Total joint arthroplasty, Bezold-Jarisch Reflex, BJR, attenuate, vasopressors, and Lower extremity total joint ONDANSETRON PRIOR TO SPINAL ANESTHESIA 5 Effect of an Educational Presentation to Increase Preemptive ondansetron Administration for Reducing Spinal-Induced Hypotension and Bradycardia Spinal anesthesia can be used for a variety of patients including those who are undergoing obstetric procedures, acute pain treatment procedures, and total joint arthroplasty (replacement). A goal of anesthesia providers is to provide analgesia while maintaining patient hemodynamics. The common hemodynamic side effects of spinal anesthesia-induced hypotension (SIH) and bradycardia are caused due to a provoked blockade of the sympathetic nervous system (Terkawi et al., 2016). These side effects can have profound effects on patients such as headache, nausea, vomiting, stroke, myocardial infarction, and death (Tubog et al., 2017). A newer treatment method has been developed, diminishing the side effects of hypotension and bradycardia from spinal anesthesia, with administration of ondansetron, a 5HT3 antagonist. Recent meta-analyses have supported the use of 5-HT3 antagonists (Terkawi et al., 2016; Tubog et al., 2017; Zhou et al., 2018). Background The utilization of lower extremity total joint arthroplasty (TJA) has increased over time with over 2.2 million hip and knee arthroplasty procedures performed between 2012 and 2020 (American Academy of Orthopaedic Surgeons, 2021). TJA, specifically total knee arthroplasty (TKA), is one of the most common orthopedic surgeries and as the US population continues to age, the rise in TJA is expected to continue (Turnbull et al., 2017). These procedures are very painful for patients; therefore, providers may choose to perform a neuraxial anesthesia to block the initiation and conduction of the pain nerve pathway (Kelly et al., 2021). Neuraxial anesthesia offers the ability to provide a deeper and longer analgesic effects compared to a general anesthetic (Kelly et al., 2021). Neuraxial anesthesia accomplishes its ability to provide a more ONDANSETRON PRIOR TO SPINAL ANESTHESIA 6 efficient analgesic by decreasing the sodium permeability of the neuronal membrane causing inhibition of motor and sensory response of the nerve (Kelly et al., 2021). Enhanced recovery after surgery (ERAS) protocols have been created to decrease the length of stay and complications (Kelly et al., 2021). ERAS protocols that contain neuraxial anesthesia have shown promise, compared to general anesthetic, in decreasing perioperative blood loss (p = 0.0662), length of stay (5.7 to 6.6 days), and a lower 30-day mortality (0.19% to 0.8%) (Kelly et al., 2021; Perlas et al., 2016). Neuraxial anesthesia is a preferred approach for TJA because patients receiving neuraxial anesthesia undergoing lower extremity TJA come with a variety of heath conditions, making their response to general anesthesia more unpredictable (Perlas et al., 2016). However, there are side effects from neuraxial anesthesia. Hypotension and bradycardia from neuraxial anesthesia is caused from its ability to elicit the Bezold-Jarisch reflex (BJR) (Tubog et al., 2017). The BJR causes a decrease in blood pressure and heart rate due to a noxious stimulus in the cardiac ventricles causing a vagal response (Ferr et al., 2020). The vagal response from BJR causes a cardioinhibitory reflex that produces hypotension through arterial and venous vasodilation and bradycardia (Tubog et al., 2017). The hypotension experienced by the patient is then exacerbated by the effects of the administered local anesthetic from the spinal anesthetic, causing further arterial vasodilation, decreased systemic vascular resistance (SVR), venous pooling, and reduction of venous return (Hofhuizen et al. 2019). Bradycardia is not only related to the BJR but can also occur from the local anesthetic that spreads higher throughout the spinal column (Balasanmugam et al., 2019). The local anesthetic could spread high enough through the spinal column and block the cardiac accelerator fibers. This would result in an imbalance between vagal fibers, resulting in a further decrease in heart rate (Hofhuizen et al., 2019) Stimulation of 5-HT3 (Serotonin) receptors commonly causes nausea and vomiting, ONDANSETRON PRIOR TO SPINAL ANESTHESIA 7 however they can also elicit the BJR. Therefore, recent meta-analyses have supported the use of 5-HT3 antagonists to attenuate the side effects of the BJR (Tubog et al., 2017). The commonly used alternatives that providers have utilized to attenuate the effects of SIH and bradycardia from neuraxial anesthesia besides 5-HT3 antagonists include; administration of crystalloid or colloid solutions, administration of vasopressor agents, and positioning changes during spinal anesthesia (Trendelenburg or lithotomy) (Ferr et al., 2020). The administration of crystalloid or colloid fluids are commonly performed by either by coloading intravenous fluid as the provider is performing the neuraxial anesthesia or before the neuraxial anesthesia is started (preloading). Preloading or pre-spinal anesthetic volume expansion, similar to co-loading, involves administering a liter of crystalloid fluid to expand the intravascular volume that is depleted during the spinal anesthesia-induced sympathectomy (Muggleton & Muggleton, 2019; Riley et al., 2019). However, co-loading or preloading can create fluid shifts during surgery or in patient populations such as those with renal disease or have congestive heart failure (CHF) it is contraindicated (Ferr et al., 2020; Muggleton & Muggleton, 2019). Vasopressor agents (ephedrine, phenylephrine, and norepinephrine) are also a commonly utilized intervention to correct SIH and bradycardia from spinal anesthesia. Prophylactic treatment with these potent alpha- and beta-receptor agonists (vasopressors) can limit the decrease in both blood pressure and heart rate (Ferr et al., 2020). Positioning changes, such as Trendelenburg (tilting of the body cephalically or lithotomy (legs elevated and supported above the heart), offer a momentary fix when intravascular volume is depleted. This temporarily displaced volume is repositioned since putting a patient in Trendelenburg moves the pooled blood in the lower extremities back to the heart increasing preload and systemic vascular ONDANSETRON PRIOR TO SPINAL ANESTHESIA 8 resistance (Ferr et al., 2020). However, each of these interventions has drawbacks, and these negative effects of alternative treatment interventions, lead to the need for a better intervention. A newer intervention used to attenuate SIH and bradycardia from elicitation of the BJR is the preoperative IV administration of ondansetron (Zofran) (Fabrcio et al., 2021). Ondansetron avoids elicitation of SIH and bradycardia while also avoiding the possibility of fluid overload or directly impacting blood pressure. The anticipatory administration of ondansetron (Zofran) prior to surgery can treats hypotension and bradycardia however, this pretreatment may be underutilized. There is a need to bring awareness of this newer approach to anesthesia providers who are directly caring for patients who receiving spinal anesthetic for procedures such as a lower extremity total joint replacement. A utilization improvement study can investigate how much does ondansetron stabilize hemodynamics when it is given versus when it is not. Ondansetron (Zofran) is a 5-HT3 antagonist also known as a serotonin antagonist, meaning it blocks the action of serotonin at the chemoreceptor zone, cardioinhibitory receptors, and circulating platelets (Ferr et al., 2020). Ondansetron is more widely used as an antiemetic and is considered the gold standard to which all other antiemetics are compared (Moro et al. 2020). Problem Statement General anesthesia for lower extremity TJA was the dominant form of anesthesia however, neuraxial anesthesia is associated with fewer complications (Turnbull et al., 2017). Patients that are receiving the lower extremity TJA under a spinal anesthetic experience a sympathetic drop in blood pressure and heart rate in 15-33% of cases (Tubog et al., 2017). Patients can experience serious outcomes if symptoms of the neuraxial anesthetic are left untreated or are severe (Tubog et al., 2017). Severe effects of SIH, hypotension, fainting, and ONDANSETRON PRIOR TO SPINAL ANESTHESIA 9 bradycardia can be less unresponsive to rescue treatment and can lead to stroke, infarction, or death. Ondansetron is a 5-HT3 that has promise of lessening the effects of SIH and bradycardia. This leads us to ask: Does an educational presentation of ondansetrons (Zofran) effects of attenuating SIH and bradycardia increase the amount of ondansetron (Zofran) that is given prophylactically? Needs Assessment & Gap Analysis This project was conducted at a community, nonprofit healthcare system in the Midwest. This hospital has at least one operating suite performing orthopedic surgery five days a week. The anesthesia providers, Certified Registered Nurse Anesthetists (CRNAs) and Anesthesiologists, at this location perform the majority of their lower extremity TJA with neuraxial anesthesia. Informal conversations revealed that a few anesthesiologists and CRNAs knew that ondansetron can be utilized as a preemptive treatment for SIH and bradycardia in which they typically chose to utilize ondansetron at the end of cases for the prevention of postoperative nausea and vomiting. However, only a few anesthesia providers appreciated ondansetron (Zofran) can be utilized as a preemptive treatment for SIH and bradycardia. This project offers to educate anesthesiologists and CRNAs that there is a safe and effective new intervention to add to their current practice. Literature Review A literature review was conducted to examine articles regarding the use of prophylactically administrating ondansetron (Zofran) as a treatment for spinal anesthesia induced hypotension and bradycardia to patients undergoing lower extremity total joint arthroplasty. The review search was conducted using the keywords ondansetron, Spinal, Neuraxial, Spinal induced hypotension, Spinal- induced hypotension Co-loading, Zofran, TJA, ONDANSETRON PRIOR TO SPINAL ANESTHESIA 10 Total joint arthroplasty, Bezold-Jarisch Reflex, BJR, attenuate, vasopressors, and Lower extremity total joint arthroplasty. This review was conducted in: October, November, and December, in 2022, and January in 2023 using the databases PubMed, CINAHL, and MedlineOvid. The databases searches were performed using the BOOLEAN phrases ondansetron AND spinal-induced hypotension, ondansetron comparison co-loading, Spinal anesthesia comparison general anesthesia, ondansetron AND total joint arthroplasty, Spinal induced hypotension AND prevention, Zofran AND lower extremity TJA, and ondansetron comparison vasopressors. The 587 database search results were reduced to exclude duplicates, upper extremity, articles published eight years ago, and not translated into English, resulting in 454 research articles shown in a PRISMA flow chart (Appendix B). The remaining research studies were examined to determine if the studies met the inclusion criteria. The search inclusion criteria included all articles written or translated into English, lower extremity total joint arthroplasty or spinalinduced hypotension treated with ondansetron, and articles that were conducting a randomized control trial (RCT). From the 168 remaining articles, research studies that consisted of secondary research and had an unrelated research purpose were excluded. Research articles were then further reduced to ten randomized control trial studies that examined whether the use of a prophylactic administration of ondansetron can stabilize hemodynamics in individuals undergoing spinal anesthesia for a lower extremity total joint arthroplasty better than without. Hemodynamic stability Effect of ondansetron on occurrence of SIH: Five recent studies conducted within the past 3 years have reported effects of prophylactic use of ondansetron in prevention of SIH and bradycardia. In a prospective randomized, double-blind controlled trial of 144 patients, Fabricio reported SIH occurred in 27.8% of patients who received ondansetron, but occurred in 50% of ONDANSETRON PRIOR TO SPINAL ANESTHESIA 11 patients who received a placebo, with statistical significance of p = 0.007 (Fabrcio et al., 2021). Tubog reported a pooled analysis of thirteen randomized control trials which showed IV ondansetron prior to spinal anesthesia compared to a placebo reduced the incidence of SIH by 12.52% (17.15% to 29.67%, respectively)(RR = 0.62; CI = 0.44-0.87; p = 0.005)(Tubog et al., 2022). In eight double blind, randomized studies of 740 patients undergoing spinal anesthesia, Chooi reported ondansetron versus the control (placebo saline) administration was more effective for preventing hypotension that required treatment (CI = 0.54 0.83) (Chooi et al., 2020). In another double-blind study of 135 patients undergoing lower limb orthopedic surgeries with a spinal anesthesia, Moro reported ondansetron showed similar effects of diminishing SIH in non-obstetric surgeries (p = 0.0006) (Moro et al., 2020). In a meta-analysis comprising of 2536 patients, a group who received ondansetron prior to a spinal anesthetic reduced the occurrence of hypotension as compared to the control group, 26.19% and 39.52% respectively (RR = 0.65; CI = 0.53-0.8; p < 0.01)(Hou et al., 2022). Kannan reported MAP between the ondansetron group and the control group there was significant attenuation of a blood pressure drop in the ondansetron group (p < 0.05)(Kannan et al., 2022). Effect of ondansetron on occurrence of bradycardia: In a meta-analysis of twenty-one randomized control trials containing 1872 patients, the incidence of bradycardia in the ondansetron group was statistically significantly lower than in the placebo group (RR = 0.43; CI = 0.51) (Zhou et al., 2018). Tubog reported in 2 randomized control studies containing 290 patients, there was statistically significant attenuation of spinal anesthesia-induced bradycardia in patients who were pretreated with ondansetron (p = 0.02; p= 0.022)(Tubog et al., 2017). In Tubogs 2 randomized control study that showed statistically significant attenuation of spinal anesthesia-induced bradycardia, collectively they evaluated 4mg, 6mg and 12mg dosages (Tubog ONDANSETRON PRIOR TO SPINAL ANESTHESIA 12 et al., 2017). In a meta-analysis of 11 randomized control studies containing 984 patients, ondansetron reduced the risk of bradycardia by 46% (RR = 0.54; 95% CI = 0.32-0.9)(Tubog et al., 2022). 18 double blind randomized control trials containing a total of 1874 patients, found that patients pretreated with ondansetron prior to a spinal anesthetic had significantly lower occurrence of bradycardia than those who received a placebo, 4.22% and 10.22% respectively (RR = 0.56; CI = 0.38-0.83; p < 0.01)(Hou et al., 2022). Effect of ondansetron on need for additional intervention: Fabricio found that in a study of TJA patients, fewer patients received rescue Ephedrine in the ondansetron group compared to the placebo, 13.9% and 27.8% respectively, indicating that ondansetron provided improved prophylaxis (p = 0.04) (Fabrcio, et al., 2021). Ondansetron compared to dexamethasone or a combination of the two was shown to more effective in limiting side effects from spinal anesthesia including, nausea, vomiting, pain scores, pruritis, and length of stay (p = 0.003) (Moro et al., 2020). Four studies concluded fewer patients in the ondansetron group received rescue ephedrine compared to the control group of patients not receiving ondansetron prior to spinal anesthetic, 19.77% and 32.56% respectively (RR = 0.61; 95% CI = 0.43 0.87; p = 0.007)(Tubog & Bramble, 2022). Fifteen double blind control trials containing 1408 patients, reported pretreatment of ondansetron significantly reduced the number of patients who required vasopressors following spinal anesthesia than those who received a placebo, 15.16% and 32.7% respectively (RR = 0.5; CI = 0.38-0.67; p<0.01)(Hou et al., 2022). Hou also reported in which four double blind, randomized control trials saw patients in the ondansetron group had a dower dose of administered ephedrine compared to the placebo group with a 2.81 mg difference (p , 0.05). In a randomized, double-blinded study of 60 patients, Xiao found the rate of prophylactic phenylephrine infusion (0.24mcg/kg/min to 0.32mcg/kg/min)(p < 0.001) and total consumption ONDANSETRON PRIOR TO SPINAL ANESTHESIA 13 of phenylephrine (315.6 25.9mcg to 387.7 14.7mcg)(p = 0.02) was lower in the ondansetron group compared to the placebo group (Xiao et al., 2020) Contraindications of current approaches Pre-emptive intravenous fluid loading has the potential for volume overload (Ceruti et al., 2018). In a RCT containing 74 patients, Farid concluded both preloading and co-loading of lactated ringers when used alone are ineffective for the prevention of hypotension in obstetric patients receiving spinal anesthetic (Farid et al., 2016). Prophylaxis use of ephedrine has been used to attenuate the effects of SIH and bradycardia; however, hypotension still occurred in 12% of cases in a randomized control study of 100 patients (Salama et al., 2016). Farid states crystalloids have a short intravascular half-life of 15-20 minutes, which decreases its efficacy for the prevision of post-spinal hypotension (Farid et al., 2016). Performance of ondansetron and side-effects of ondansetron Timing for peak effect during spinal anesthetic was reported when it was administered 30 minutes prior to neuraxial anesthetic (DailyMed, 2018; Kleinman, 2021; Lexicomp, 2023; Medscape, 2021). A reduction of hypotension was not shown to be increased with a larger dose of ondansetron, 6mg or 8mg, as compared to the control 4mg (Tubog et al., 2017). The amount of emergency vasopressors was diminished in patients with a prophylactic treatment of ondansetron compared to a placebo (p = 0.002) (Terkawi et al., 2016). The heart rate, systolic blood pressure, and diastolic blood pressure 20 minutes after the start, as well as 15 minutes before the end, of the operation were higher in the ondansetron pre-treatment group (p < 0.05; p < 0.05) (Zhong et al., 2019). The incidence of postoperative adverse reactions such as nausea & vomiting (2% to 14.29%), hypotension (p <0.05), and pulmonary infection (2% to 14.29%), were ONDANSETRON PRIOR TO SPINAL ANESTHESIA 14 lower in the ondansetron group with a combined spinal-epidural anesthetic compared to those who received a general anesthetic without the ondansetron (Zhong et al., 2019). Framework The evidence-based practice model that was utilized as the framework is the Johns Hopkins Nursing Evidenced-Based Practice (JHNEBP) model (Appendix A). The Johns Hopkins Nursing Evidenced-Based Practice model is a problem-solving approach to clinical decisionmaking (Dang et al., 2022). This model is used to determine a problem that an organization deems a priority, and, if high quality evidence exists, provides a process to evaluate if it is feasible to incorporate into practice of the organizations providers (Dang et al., 2022). The JHNEBP models uses a three-step process called PET: practice question, evidence, and translation (Dang et al., 2022). The goal of this model is to ensure that the latest research findings and best practices are quickly and appropriately incorporated into patient care (Dang et al., 2022). The JHNEBP model (Appendix A) guides the project by laying out all the pieces to accomplish each step. The first step, practice questions, begins with recruiting an interprofessional team; determining responsibility/leadership for the project; scheduling team meetings to clarify and describe the problem; developing/refining the question being asked and determining the need; and identifying the stakeholders (Dang et al., 2022). The second step, evidence, begins with conducting internal and external search of evidence; appraising the level and quality of the evidence; summarizing the evidence; synthesizing the findings; and developing best evidence recommendations (Dang et al., 2022). The last step, translation, begins with notifying practice setting and specific recommendations; creating an action plan; secure support and resources to implement plan; implementing the plan; evaluation of the plan and ONDANSETRON PRIOR TO SPINAL ANESTHESIA 15 making changes; reporting results to the stakeholders; identifying the next steps, and finally, disseminating the findings (Dang et al., 2022). Project Aims and Objectives This quality improvement project aimed to increase the knowledge of CRNAs and anesthesiologists at the project site on the benefits of using ondansetron prior to spinal anesthesia in patients undergoing a total knee arthroplasty to attenuate hypotension and bradycardia. The secondary aim of this project aimed to increase the number of successful, prophylactic administrations of ondansetron by providing education on this newer prophylactic treatment. The objectives were as follows: -Include CRNAs and anesthesiologist physicians. -Provide an online-pre-test to evaluate knowledge of current evidence-based practice regarding ondansetron. -Provide an online-voiced over educational intervention immediately following the pre-test. -Provide an online post-test immediately following the educational intervention to assess knowledge gained from the educational intervention and willingness to change practice. -Perform a retrospective chart review from three months prior to educational intervention to determine when ondansetron was administered in comparison to spinal anesthetic administration -Perform a retrospective chart review to determine when ondansetron was administered for three months following the educational intervention to determine if a practice change was made Project Design & Methods This project evaluates if presenting current literature to anesthesia providers improves prophylactic administration of ondansetron for SIH and bradycardia for individuals undergoing ONDANSETRON PRIOR TO SPINAL ANESTHESIA 16 lower extremity total joint arthroplasty under spinal anesthesia. This project utilized a pretest, educational presentation, posttest, and retrospective chart review. To obtain participants in the project I arrived at the project site three separate times and introduced myself in person to the CRNAs and anesthesiologists to obtain written consent. I explained the project and also provided them the consent (Appendix F). To allow for the greatest number of participants I also elicited the help of my project site chair (Adrienne Merrick) to obtain the emails of the anesthesia staff (CRNAs and anesthesiologists) to ensure all anesthesia staff at the project site had the opportunity to participate even if they missed the in-person explanation. I additionally left a copy of the entire consent and the written consent when I left the site visit in the anesthesia break room to allow them time to read and fill out the consent at their leisure for two additional weeks. After a month to allow the greatest number of applicants to participate, the pretest was given in May of 2023. After the one month timeframe to allow for completion of the written consent, emails on the completed consent was used to send the anonymous link for the anesthesia providers to complete the pretest in two weeks. The pretest sent to anesthesia providers assessed their current knowledge, usage, and way they treat or prevent SIH and bradycardia. Next, immediately following the pretest, current literature was presented of prophylactic administration of ondansetron and its effect on reducing SIH, bradycardia, and vasopressor usage. The educational intervention was a virtual voiced-over PowerPoint linked on the pre-test. Through a QR code, attached to the educational intervention a reference sheet was provided containing sources from the literature review. The posttest was administered to the participants immediately following the educational presentation through a link on the educational intervention to evaluate the educational material by assessing knowledge retention. After the conclusion of the two weeks of pretest, educational presentation, and ONDANSETRON PRIOR TO SPINAL ANESTHESIA 17 posttests; weekly retrospective chart reviews of all patients receiving total knee arthroplasty under a spinal anesthetic were analyzed to see if there was an increase in prophylactic ondansetron administration. The retrospective chart review was conducted in the months of June and July and were compared to all patients who received a total knee arthroplasty under a spinal anesthetic during the months of March and April. The retrospective chart review analyzed the dose and time of ondansetron administration to ensure it was given within the 30 minutes to 3 hour time range of ondansetron effectiveness and compared it to the 2 months prior to the educational presentation to the 2 months post-educational presentation. Materials & Tools Pretest & posttest The pretest and posttest were conducted utilizing Qualtrics Online Survey Software provided by Marian University. The pretest includes five knowledge-based questions containing multiple choice questions and one quantitative questions in the form of a Likert scale that are the same on for each test (Appendix C & D). The pretest and post-test were validated by committee members to review the questions to establish face validity. Educational presentation The educational presentation was created on PowerPoint and uploaded on Qualtrics Online Survey System that has a link to a voice recorded presentation and references showing that administering ondansetron prophylactically has positive effects on reducing SIH, bradycardia, and vasopressor usage (Appendix E). The educational presentation is embedded in the Qualtrics in-between the pretest and posttest questions. ONDANSETRON PRIOR TO SPINAL ANESTHESIA 18 Retrospective chart review & collection The retrospective chart review was conducted utilizing Cerner, the electronic health record (EHR) software of the project site. Data collection from the patients electronic medical record (EMR) was collected through a data pull conducted by the project site to avoid any unnecessary breach of confidentiality and limit the risk to patients. Data collection from the retrospective chart review only observes if and when ondansetron (Zofran) was given during the surgical procedure (lower extremity total knee arthroplasty under a spinal anesthetic). Criterion for a correct prophylactic administration of ondansetron (Zofran) is if it was given prior to 30 minutes to 3 hours of the spinal anesthetic, this would indicate a successful prophylactic dose and be collected as a S. A prophylactic dose of ondansetron (Zofran) given less than 30 minutes prior to the spinal anesthetic was collected as an improper I administration. A patient who receives a lower extremity total joint arthroplasty under a spinal anesthetic without an administration of ondansetron (Zofran) or 3 hours after the spinal anesthetic was administered as failed F prophylactic administration. Statistical analysis The statistical analysis was performed by Qualtrics Online Survey Software. A paired ztest for two population proportions and a one-way repeated measures ANOVA was used to assess the significance difference between the prophylactic ondansetron (Zofran) administration 1 months prior to the educational presentation to the conclusion of the educational presentation to 1 months post-educational presentation. The criterion for statistical significance was p values < 0.05. ONDANSETRON PRIOR TO SPINAL ANESTHESIA 19 Data Analysis Effectiveness of the pretest and post-test was evaluated through McNemars test to determine if the anesthesia providers improved their knowledge. McNemar's test was utilized since there are two paired groups, for instance, patients before and after the educational presentation. Additionally, the values are dichotomous (i.e., a variable with only two categories) such as correct and incorrect responses. To determine if the projected influenced practice from the retrospective chart review a z-test was conducted for two population proportions, along with a one-way repeated measures ANOVA, and usage rate of prophylactically administering ondansetron. A z-test was selected a t-test because while population standard deviation was unknown, the sample size warranted the use of the z-test. Question 6 on the posttest warranted the use of the one-way repeated measures ANOVA since it is a rank-based nonparametric test that can between two or more groups of an independent variable. The project evaluation plan was multifaceted. First, the quantitative data was analyzed with descriptive statistics using Qualtrics Online Survey Software to review the characteristics of the pretest and posttest. The quantitative data was analyzed utilizing a paired t-test. The Likert data was analyzed utilizing the mean and median results. Second, an anonymous, data pull was performed by a member of project sites Clinical Research Systems to receive data, from a retrospective chart review, providing times in which Ondansetron was given and the time of the spinal anesthetic was administered in patients. This data was collected in aggregate reflecting two months pre-education and two month post-education. ONDANSETRON PRIOR TO SPINAL ANESTHESIA 20 Ethical considerations Written and informed consent was obtained by all providers willing to participate in this project.. The consent is listed in (Appendix F). All consent forms were collected by the DNP student and will be maintain in a secure location separate from data to protect provider identity. Electronic data from the project is being kept for a minimum 2 years and maximum of 5 years. The pretest and posttest project (move this to the pretest and posttest data is protect by a password on Qualtrics Online Survey Software. The data has a second layer of protection by also having a password on my personal computer. These two passwords are not the same. After receiving the organizations and Marian Universitys Institutional Review Board (IRB) approval Results Of the 33 members of the project sites anesthesia team only 5, 15.2%, participated. The retrospective chart review resulted in a total of 39 total knee arthroplasty under a spinal anesthetic cases during the months of June & July and 38 cases during September & October. Pretest & Posttest Results Question 1, 2, and 4 on the pretest and posttest (Appendix C and D & Table 1) evaluated current knowledge and if the educational presentation was effective at teaching key points on the Bezold-Jarisch Reflex, onset time of ondansetron, and half-life of crystalloid fluid, respectively. McNemars test was utilized to evaluate if these questions. This test was chosen over others due to the data being nominal and paired and to determine if there are differences (improvement) post-education. There were a few notable areas in which the intervention did improve knowledge of prophylactic administration of ondansetron for total knee arthroplasty under a spinal anesthetic was the identification of the reflex that elicits hypotension & bradycardia, ondansetron peak onset time, and the half-life time of crystalloids. However, these questions 21 ONDANSETRON PRIOR TO SPINAL ANESTHESIA were not a statistically significant improvement from the pretest and posttest demonstrated by a limited increase in the score. Table 1 Pretest-Posttest Survey Results (n=5) Question Number by Topic Number of correct responses Pretest Posttest p-value: n % n % Hypotension and bradycardia from a spinal anesthetic is elicited by what reflex? Question 1 2 40 4 80 0.099 How early should you administer ondansetron (Zofran) to have its peak effect when you desire? Question 2 3 60 5 100 0.057 What is the intravenous half-life of crystalloids? Question 4 4 80 5 100 0.147 Question 3 on the pretest and posttest (Appendix C and D & Table 2) evaluated current knowledge on the Bezold-Jarisch Reflex and if the educational presentation was effective at teaching possible surgical scenarios or medication administrations that can elicit the reflex. McNemars test was also utilized to evaluate statistical significance. Most of the selection options (A, C, D, F, & G) did not show statistically significant results, but all did improve from the pretest post-education. Additionally, Question 3 did show statistically significant improvement from the pretest to the posttest in two option choices, however both options (B & E) were incorrect responses on the select all that apply. Due to options B & E not being chosen on question 3 on the pretest and posttest, both options are statistically significant with a p-value < 0.001 since they were never selected on either test. 22 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Table 2 Pretest-Posttest Survey Results (n=5) Question Number by Topic Number of correct responses Pretest Posttest p-value: n % n % Select all that can elicit the Bezold-Jarisch Reflex? Question 3 a. 5-HT3 receptor agonist b. 5-HT3 receptor antagonist c. Noxious stimuli to the cardiac ventricles d. Local anesthetic e. Ondansetron (Zofran) f. Hemorrhage g. Beach-chair position 3 60 4 80 0.245 0 0 0 0 2 40 4 80 0.099 2 0 40 0 3 0 60 0 0.264 < 0.001 1 3 20 60 3 3 60 60 0.099 0.5 < 0.001 Question 6 on the pretest (Appendix C & Table 3) asked the providers to rank what were their pre-educational presentation interventions were for attenuating the Bezold-Jarisch reflex. 60% of providers said preloading crystalloids were their top choice at attenuating the BezoldJarisch reflex from the spinal anesthetic. The remaining 40% of providers had preloading crystalloids as their second choice behind co-loading crystalloids and prophylactically administering ondansetron. 80% of the providers who completed the pretest and posttest said prophylactically administering vasopressor(s) and/or anticholinergic were their least common method. 23 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Table 3 Posttest Survey Result (n=5) Rank your current interventions you utilize to attenuate spinal-anesthetic induced hypotension (SIH) and bradycardia. (ranking 1 4 with 4 being top choice) 1 2 3 4 n= 4 n= 1 n=0 n= 0 n= 1 n= 2 n=1 n= 1 n= 0 n= 0 n= 2 n= 0 n=2 n=2 n= 1 n= 3 Question 6 (pretest) a. Prophylactic vasopressor(s) and/or anticholinergic b. Prophylactic ondansetron (Zofran) c. Co-load crystalloid/colloid d. Preload crystalloid/colloid Question 6 on the posttest asked the Anesthesiologists and CRNAs to rank their current they currently utilize to attenuate spinal-anesthetic induced hypotension (SIH) and bradycardia for patients undergoing lower extremity total joint arthroplasty under a spinal anesthetic. Question 6 on the posttest warranted the use of the one-way repeated measures ANOVA since it is a rank-based nonparametric test that can between two or more groups of an independent variable. 80% of the participants were split equally between two choices: limited data on the prophylactically administering ondansetron to attenuate the effects of the Bezold-Jarisch reflex caused by the spinal anesthetic and not knowing this was even an intervention that could be utilized. This was not statically significant with a p-value of 0.143. The remaining 20% said the efficacy from alternative interventions were sufficient enough to not utilize ondansetron for patients undergoing lower extremity total joint arthroplasty under a spinal anesthetic. 24 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Table 4 Posttest Survey Result (n=5) Please select what reasons you currently do not preemptively administer ondansetron (Zofran) for patients undergoing lower extremity total joint arthroplasty under a spinal anesthetic? p-value: 0.143 Question 6 (posttest) a. b. c. d. e. Limited data of intervention Not a previously known intervention Side effects of Ondansetron (Zofran) Cost Efficacy from alternative interventions n= 2 n= 2 n= 0 n= 0 n= 1 40 40 0 0 20 Question 5 on the pretest and posttest (Appendix C and D & Table 5) asked the anesthesiologists and CRNAs the percentage of cases are they were (pre-educational presentation on pretest) to now (post-educational presentation on posttest) likely to prophylactically administer ondansetron (Zofran) to attenuate spinal-anesthetic induced hypotension (SIH) and bradycardia. Statistically significant improvement was determined for question 5 on the pretest and posttest. anesthesiologists and CRNAs were asked to rank their usage utilizing a Likert scale which allowed them to slide their answer as a percentage which contained 10% increments. In the pretest, only 2 participants stated they prophylactically administered ondansetron (Zofran) to attenuate spinal-anesthetic induced hypotension (SIH) and bradycardia averaging 40% of their total knee arthroplasty surgeries under spinal anesthetic. In the posttest, all 5 participants stated they were now likely to prophylactically administer ondansetron (Zofran) to attenuate spinalanesthetic induced hypotension (SIH) and bradycardia. The percentage of cases CRNAs and anesthesiologists stated they would likely administer ondansetron (Zofran) prophylactically averaged 93% post-education in the posttest survey. A t-test was utilized to record the participants scores and resulted in a p-value <0.001. 25 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Table 5 Pretest-Posttest Survey Results (n=5) Question 5 Percentage of usage of ondansetron Pretest p-value: Posttest n % n % 2 40 5 93 < 0.001 Retrospective Chart Review Results The second aspect of the project was to determine to see if there is an increase in prophylactic ondansetron administration for lower extremity total joint arthroplasty under a spinal anesthetic. A t-test was utilized to properly assess for statistical significance for the retrospective chart review. Criterion for a correct prophylactic administration of ondansetron (Zofran) was only given if ondansetron was given prior to 30 minutes to 3 hours of the spinal anesthetic. A successful prophylactic dose was collected as a S. A prophylactic dose of ondansetron (Zofran) given less than 30 minutes prior to the spinal anesthetic was collected as an improper I administration. A patient who receives a lower extremity total joint arthroplasty under a spinal anesthetic without an administration of ondansetron (Zofran) or 3 hours after the spinal anesthetic was administered as failed F prophylactic administration. There were a total 39 lower extremity total joint arthroplasty under a spinal anesthetic cases during the months of June & July and 38 cases during September & October. The months of June and July had an equal amount of 7 cases in which ondansetron was administered satisfactory and improper. To reiterate the conditions in what is satisfactory and improper, ondansetron must have been administered at least 30 minutes before the administration of the spinal anesthetic and up till 3 hours to be considered successful, any administrations under 30 minutes were marked as improper. There were 25 cases each during the months of June & July and September & October that were marked as failed administrations where ondansetron was administered after the spinal 26 ONDANSETRON PRIOR TO SPINAL ANESTHESIA anesthetic was administered or 3 hours before the spinal anesthetic administration. The failed prophylactic administrations of ondansetron for lower extremity total joint arthroplasty under a spinal anesthetic were not statistically significant p-value 0.436. During the months of September & October the number of satisfactory prophylactic administration increased from 7 to 10, however this not statistically significant p-value 0.189 (Table 6). The same months also showed a decrease in improper prophylactic administrations of ondansetron from 7 to 3. This decrease in improper ondansetron administration for lower extremity total joint arthroplasty under a spinal anesthetic was also not statistically significant pvalue 0.095 (Table 6). Table 6 Retrospective Chart Review Results Type of Administration Number of Cases p-value: June & July (n = 39) September & October (n = 38) n % n % Satisfactory 7 17.95 10 26.32 0.189 Improper 7 17.95 3 7.89 0.095 Failed 25 64.1 25 65.79 0.436 Discussion Pretest & Posttest Some questions, specifically question numbers 1, 2, and 4 on the pretest and posttest, showed the positive change was not statistically significant. The increase in total scores of the survey suggest a generalized improvement in current knowledge and that the educational presentation was effective at teaching key points on the Bezold-Jarisch Reflex, onset time of ondansetron, and half-life of crystalloid fluid, respectively. Despite not being statistically ONDANSETRON PRIOR TO SPINAL ANESTHESIA 27 significant, this could imply that the subject matter of those questions was not retained effectively by the participants from the educational presentation. However, with just a sample size of 5, prior knowledge of Bezold-Jarisch Reflex, onset time of ondansetron, and half-life of crystalloid fluid, an overall improvement of less than 3 participants would result as insignificant statistical improvement. Question 3 on the pretest and posttest evaluated current knowledge on the Bezold-Jarisch Reflex and if the educational presentation was effective at teaching possible surgical scenarios or medication administrations that can elicit the reflex. Most of the selection options (A, C, D, F, & G) did not show statistically significant results, but all did improve from the pretest posteducation. Additionally, Question 3 did show statistically significant improvement from the pretest to the posttest in two option choices, however both options (B & E) were incorrect responses on the select all that apply. Due to options B & E not being chosen on question 3 on the pretest and posttest, both options are statistically significant with a p-value < 0.001 since they were never selected on either test. Question 6 on the pretest provided us data on interventions providers currently utilize to combat the effects of the Bezold-Jarisch reflex. On Table 1 we saw the majority of providers chose to preload crystalloids, the purpose of this was to prophylactically treat or attenuate the effects of the Bezold-Jarisch reflex. Crystalloids half-life is within the range of 20-40 minutes, this can be concerning as the effects of the spinal anesthetic will outlast the intravascular volume expansion to combat the cardioinhibitory and vasodilatory effects of the Bezold-Jarisch reflex. Since 80% of the top two choices of the providers surveyed involved administering crystalloids, preloading and co-loading, to attenuate the effects of the Bezold-Jarisch reflex; improvement on ONDANSETRON PRIOR TO SPINAL ANESTHESIA 28 the educational presentation with emphasis on the potential for fluid overload especially in those with heart and kidney disease needs to be made. Question 6 on the posttest answered why the participating Anesthesiologists and CRNAs were not prophylactically using of ondansetron for total knee arthroplasty under a spinal anesthetic to attenuate the effects of the Bezold-Jarisch reflex. The identifiable areas showed 80% of the participants were not previously informed of this intervention or they felt there was not sufficient data on the intervention to attenuate the Bezold-Jarisch reflex. At this particular clinical site they have an enhanced recovery after surgery (ERAS) protocol. A few of the objectives the protocol makes is to increase the use of regional/neuraxial anesthesia to reduce the use of opioids and limit the total fluid intake from the continuous crystalloid infusion. The limited side effects of ondansetron and it's property to limit or attenuate the effects of the Bezold-Jarisch reflex could make an argument that it could be integrated into the ERAS protocol at this Hospital. Ondansetrons ability to attenuate the reflex would limit the amount of fluid that is preloaded/ co-loaded along with maintaining homeostasis for patients that may not tolerate large alterations in vital signs. There was only one question on the pretest and posttest that was deemed statistically significant, question 5. The educational presentation was successful at promoting the use of prophylactic use of ondansetron for total knee arthroplasty under a spinal anesthetic. The posttest survey of 93% average offers a bit more room for improvement, but the directional change was net positive. This allows us to recognize to improve up the educational presentation to fill the knowledge gap. ONDANSETRON PRIOR TO SPINAL ANESTHESIA 29 Retrospective Chart Review Similar case numbers during the two month comparison lead to a great examination of the two. Overall the notable impression from the comparison was the equal number of failed prophylactic administrations of ondansetron for total knee arthroplasty under a spinal anesthetic. The lack of improvement of the failed attempts may reflect the amount of providers who participated in the educational presentation or providers discretion to administer ondansetron at the end of the case to prevent post-operative nausea and vomiting (PONV) in the post-operative anesthesia care unit (PACU). Due to the data pull being anonymous and being conducted through the project site, CRNAs and anesthesiologists who performed the anesthesia for these cases may have not been the participants in the project therefore, they did not get any education on the benefits of prophylactic administration of ondansetron prior to a spinal anesthetic. This variable could affect the results as CRNAs and Anesthesiologists who did not participate in the project would not know the benefits and correct administration time of ondansetron compared to spinal anesthetic administration. While ondansetron is considered the gold standard of antiemetics; PONV can be attributed to hypotension especially since under a spinal anesthetic there should be less opioid administration, no volatile anesthetic, and propofol administration which all contributes to less PONV (Moro et al. 2020). Another area that was noticeable during examination of the collected failed administrations were ondansetron administrations after the spinal anesthetic was administered but, at least an hour before the end of the procedure. A count of these cases were not recorded in the final results and may be worth investigating in future studies, but actions such as a delay in charting or vomiting from hypotension from the spinal anesthetic cannot be ruled out as these events were not noted. ONDANSETRON PRIOR TO SPINAL ANESTHESIA 30 The number of satisfactory administrations did increase post-educational presentation, however it was not deemed statistically significant and may imply that the educational presentation was successful, but the CRNAs and Anesthesiologists who performed the improper and failed administrations may have not participated in the educational opportunity. The comparison of the two months of data pre- and post-educational presentation showed there was a decrease in the amount of improper administrations of ondansetron. This finding was not statistically significant however, in larger, future studies the lack of improper administrations could contribute to more accurate statistics. The decrease in improper administrations was a promising finding as the educational presentation was successful at teaching the onset of ondansetron. Strengths and Limitations The anonymous, data pull from the hospital was another strength of the project as it was able to protect any unnecessary healthcare information to be shared or received. The anonymous data pull allowed our team to repeat our post-educational collection of data under the same program. Since the data was able to be collected in aggregate and in the same manner, not only were the results reliable, comparison and data analysis was very manageable and easily repeatable if this were to be a longitudinal study. The educational presentation was recorded and was provided to the participants to go through at their own time along to ensure all participants received the same presentation. The availability of the project site was helpful in creating a collective project team since all necessary aspects were in one location. Limitations to the project were the lack of participants for the pretest, educational presentation, and posttest. Not only did this lack of participation decrease the amount of CRNAs and Anesthesiologists that were exposed to an intervention; a vast portion of the participants ONDANSETRON PRIOR TO SPINAL ANESTHESIA 31 were not familiar with , but a response rate of 15.15% lead to statistics that can be skewed by outliers. Promotion to complete the surveys and educational presentation may have not been adequate despite multiple means. Promotion to complete the surveys were sent via email, with contact information, on three separate occasions along with site visits on two separate occasions to answer any questions regarding the project. Retrospective chart review did not exclude nonparticipants. Conclusion This project provided insight into how an educational presentation of a newer intervention to promote safe and effective anesthesia can benefit from continuing education. Specifically, CRNAs and Anesthesiologists showed an improvement in key points on the educational presentation, knowledge retention, satisfactory prophylactic administrations, and a decreased number of improper prophylactic administrations of ondansetron for total knee arthroplasty under a spinal anesthetic. Future DNPS may continue investigation on this project as a longitudinal study at other healthcare institutions. Recruitment or a involving multiple healthcare institutions may lead to improved statistics as a sample size of 5 is too small to see statistically significant improvement. there are limitations to this project, these interventions can effectively improve current levels of understanding. As continuing education is a hallmark and mandatory of advanced practicing providers such as CRNAs and Anesthesiologists; the hope is that education on newer interventions like this project will produce safe and competent care providers. Eventually with increased participation this would likely yield better patient outcomes through the avoidance of alterations in vital signs and knowledge of situations where alternative interventions is not indicated. 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Does ondansetron Modify Sympathectomy Due to Subarachnoid Anesthesia? Anesthesiology, 124 (4)., pp. 846-869. doi: 10.1097/ALN.0000000000001039 Retrieved December 1, 2022 from https://oce-ovidcom.forward.marian.edu/article/00000542-201604000-00024/HTML Xiao, F., Wei, C., Chang, X., Zhang, Y., Xue, L., Shen, H., Ngan K., Warwick, D., & Chen, X. (2020). A prospective, randomized, double-blinded study of the effect of intravenous ondansetron on the effective dose in 50% of subjects of prophylactic phenylephrine infusions for preventing spinal anesthesia-induced hypotension during cesarean delivery. Anesthesia & Analgesia. 131(2). 564-569. Retrieved January 23, 2023 from ONDANSETRON PRIOR TO SPINAL ANESTHESIA 39 https://journals.lww.com/anesthesiaanalgesia/Fulltext/2020/08000/A_Prospective,_Randomized,_Double_Blinded_Study_of.3 4.aspx Zhong, H., Wang, Y., Wang, Y., & Wang, B. (2019, June). Comparison of the effect and clinical value in general anesthesia and combined spinal-epidural anesthesia in elderly patients undergoing hip arthroplasty. Experimental and Therapeutic Medicine. Retrieved December 4, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6489064/ Zhou, C., Zhu, Y., Bao, Z., Wang, X., & Liu, Q. (2018). Efficacy of ondansetron for spinal anesthesia during cesarean section: a meta-analysis of randomized trials. The Journal of International Medical Research, 46(2), pp. 654662. Retrieved December 4, 2022 from https://doi.org/10.1177/0300060517716502 40 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Appendix A Johns Hopkins Nursing Evidence-Based Practice Model Dang, D., Dearholt, S., Bissett, K., Ascenzi, J., & Whalen, M. (4th ed.) (2022). Johns Hopkins evidence-based practice for nurses and healthcare professionals: Model and guidelines. Sigma Theta Tau International The Johns Hopkins Hospital/The Johns Hopkins University (used with permission) ONDANSETRON PRIOR TO SPINAL ANESTHESIA 41 Appendix B PRISMA 2020 Flow Diagram Included Screening Identification Identification of studies via databases Records identified from* Databases (n = 587 ) PubMed (n =554 ) CINAHL (n = 32) Medline-Ovid (n = 1) Records removed before screening: Duplicate records removed (n = 43 ) Records removed for other reasons (n = 90) Records screened (n = 454 ) Records excluded (n =284) Reports assessed for eligibility (n = 170) Reports excluded: Epidural (n = 4) Peripheral nerve block (n = 62) Other 5-HT3 antagonists (n = 66) Comparison between other alternative treatment methods (n = 23 ) Studies included in review (n = 15) *Consider, if feasible to do so, reporting the number of records identified from each database or register searched (rather than the total number across all databases/registers). **If automation tools were used, indicate how many records were excluded by a human and how many were excluded by automation tools. From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71 For more information, visit: http://www.prisma-statement.org/ ONDANSETRON PRIOR TO SPINAL ANESTHESIA Appendix C Pretest 1. Hypotension and bradycardia from a spinal anesthetic is elicited by what reflex? a. Bainbridge Reflex b. Baroreceptor Reflex c. Bezold-Jarisch Reflex d. Cushing Reflex 2. How early should you administer ondansetron (Zofran) to have its peak effect when you desire? a. 5 minutes b. 15 minutes c. 30 minutes d. 45 minutes e. 1 hour 3. Select all that can elicit the Bezold-Jarisch Reflex? a. 5-HT3 receptor agonist b. 5-HT3 receptor antagonist c. Noxious stimuli to the cardiac ventricles d. Local anesthetic e. Ondansetron (Zofran) f. Hemorrhage g. Beach-chair position 4. What is the intravenous half-life of crystalloids? a. 5- 10 minutes b. 10 - 20 minutes c. 20- 40 minutes d. 40- 60 minutes 5. What percentage of cases do you currently prophylactically administer ondansetron (Zofran) to attenuate spinal-anesthetic induced hypotension (SIH) and bradycardia? a. Likert Scale 0% - 100% (10% increments) 6. Rank your current interventions you utilize to attenuate spinal-anesthetic induced hypotension (SIH) and bradycardia. a. Prophylactic vasopressor(s) and/or anticholinergic b. Prophylactic ondansetron (Zofran) c. Co-load crystalloid/colloid d. Preload crystalloid/colloid 42 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 43 Appendix D Posttest 1. Hypotension and bradycardia from a spinal anesthetic are elicited by what reflex? a. Bainbridge Reflex b. Baroreceptor Reflex c. Bezold-Jarisch Reflex d. Cushing Reflex 2. How early should you administer ondansetron (Zofran) to have its peak effect when you desire? a. 5 minutes b. 15 minutes c. 30 minutes d. 45 minutes e. 1 hour 3. Select all that can elicit the Bezold-Jarisch Reflex? a. 5-HT3 receptor agonist b. 5-HT3 receptor antagonist c. Noxious stimuli to the cardiac ventricles d. Local anesthetic e. Ondansetron (Zofran) f. Hemorrhage g. Beach-chair position 4. What is the intravenous half-life of crystalloids? a. 5- 10 minutes b. 10 - 20 minutes c. 20- 40 minutes d. 40- 60 minutes 5. What percentage of cases are you now likely to prophylactically administer ondansetron (Zofran) to attenuate spinal-anesthetic induced hypotension (SIH) and bradycardia? a. Likert Scale 0% - 100% (10% increments) 6. Please select what reasons you currently do not preemptively administer ondansetron (Zofran) for patients undergoing lower extremity total joint arthroplasty under a spinal anesthetic? a. Limited data of intervention b. Not a previously known intervention c. Side effects of Ondansetron (Zofran) d. Cost e. Efficacy from alternative interventions ONDANSETRON PRIOR TO SPINAL ANESTHESIA Appendix E Educational Presentation 44 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 45 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 46 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 47 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 48 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 49 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 50 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 51 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 52 Appendix F Consent INDIANA UNIVERSITY INFORMED CONSENT STATEMENT FOR DOCTOR OF NURSING PRACTICE PROJECT Effect of an Educational Presentation to Increase Preemptive ondansetron Administration for Reducing Spinal-Induced Hypotension and Bradycardia IRB Protocol Number 19389 Site-Specific Primary Investigator: Adrienne Merrick, CRNA Co-Investigator: Cody Brandes, BSN, RN, CCRN DNP Chair Member: Bradley Stelflug, DNP, CRNA ABOUT THIS PROJECT You are being asked to participate in a Doctor of Nursing Practice (DNP) Project. This consent form will give you information about this project to help you decide whether you want to participate. It is your choice whether or not you want to be in this DNP Project. Please read this form, and ask any questions you have, before agreeing to be in this DNP Project. PROJECT SUMMARY We are interested educating how preemptive ondansetron administration reduces spinal anesthesia-induced hypotension and bradycardia. For this project, the first part, you will take a pretest to understand your current knowledge and usage of preemptive ondansetron administration to reduce spinal anesthesia-induced hypotension and bradycardia. Next, you will be presented with information relevant to how preemptive ondansetron administration reduces spinal anesthesia-induced hypotension and bradycardia. Then, you will be asked to answer some questions about it. Your responses will be kept completely confidential. WHY IS THIS DNP PROJECT BEING DONE? ONDANSETRON PRIOR TO SPINAL ANESTHESIA 53 The primary aim of this project is to increase the use of ondansetron by providing education on this newer prophylactic treatment to anesthesia providers who provide spinal anesthesia to patients undergoing total knee arthroplasty. The secondary aim of this project is to evaluate knowledge retention from the educational presentation of a newer prophylactic treatment to anesthesia providers who provide spinal anesthesia to patients undergoing total knee arthroplasty. We are asking you if you want to be in this DNP Project because as anesthesia providers who provide spinal anesthesia to patients undergoing total knee arthroplasty you deal with the side effects of eliciting the Bezold-Jarisch Reflex causing hypotension, bradycardia, and venous dilation. Anesthesia providers have the free will to choose what medications they wish to give to combat the side effects from the spinal anesthetic, however informal conversations revealed that a few providers know that ondansetron can be utilized as a preemptive treatment for spinalinduced hypotension (SIH) and bradycardia. Providers at this facility typically chose to utilize ondansetron at the end of cases for the prevention of post-operative nausea and vomiting. However, only a few anesthesia providers appreciated ondansetron (Zofran) can be utilized as a preemptive treatment for SIH and bradycardia. The DNP Project is being conducted by: Adrienne Merrick, IU Health Arnett, Site-Specific Primary Investigator Cody Brandes, Marian University,, Co-Investigator Bradley Stelflug, Marian University, DNP Chair Member WHAT WILL HAPPEN DURING THE PROJECT? For this project, the first part, you will take a pretest on Qualtrics to understand your current knowledge and usage of preemptive ondansetron administration to reduce spinal anesthesiainduced hypotension and bradycardia. Next, you will access a link after the pretest to be presented with information relevant to how preemptive ondansetron administration reduces spinal anesthesia-induced hypotension and bradycardia. Then, you will be asked to answer some questions about it to assess for knowledge retention of the educational presentation. The pretest, educational presentation, and posttest should take you around 20 minutes to complete. This will be available to complete for two weeks ONDANSETRON PRIOR TO SPINAL ANESTHESIA 54 The second part of the project involves a retrospective chart review of patients who received a lower extremity total joint arthroplasty (replacement) under a spinal-anesthetic. This retrospective chart review will be conducted 2 months prior to the educational presentation and for two months after the educational presentation. The aim is to assess if by providing education on ondansetron (Zofran) reducing the effects of spinal-induced anesthetic to anesthesia providers who provide spinal anesthesia for patients undergoing total knee arthroplasty will increase the use of ondansetron (Zofran) being used prior to the administration of a spinalanesthetic. This will be a comparison between the two months prior to the educational presentation and two months post-education to see if there is an increase in usage. Dissemination of the findings will be presented to the anesthesia providers after the conclusion of the retrospective chart review. If you participate in this DNP Project, we may learn things about you from the DNP Project procedures that could be important or interesting to you. WHAT ARE THE RISKS OF TAKING PART IN THE DNP PROJECT? Loss of Confidentiality: Anesthesia provider's responses will be confidential. I will not be collecting any information from the anesthesia providers that can be linked back to them. I am solely looking to see if there was a knowledge growth from my educational presentation on ondansetron being administered prophylactically for patients undergoing lower extremity total joint arthroplasty and if there was an increase for prophylactic ondansetron administration when retrospectively observing patients who underwent the projects criteria two months prior to the educational presentation and then two months post education. Patient Confidentiality: The patients risks will be minimized and protected by the data pull that redacts all patient information. Due to the utilization of the pretest, educational presentation, and posttest all being online utilizing Qualtrics. All information is stored electronically and is safeguarded since it is password protected. I will be the only one assessing the data which I will only have the password to Qualtrics and it is stored on my own personal laptop that is also password protected. This dual security with different passcodes will protect against leaked results as well. No paper or written results will be collected. Ondansetron (Zofran): Anesthesia providers have free will to choose whether it is appropriate to administer. The most commonly reported side effects (occurring in more than 10% of adults) include headaches, ONDANSETRON PRIOR TO SPINAL ANESTHESIA 55 fatigue, dry mouth, malaise, and constipation. Some less common effects range from central nervous system (CNS) manifestations, such as drowsiness and sedation, to local injection site reactions and pruritus. Typically clinically insignificant, EKG interval changes such as QTc elongation can be seen. These changes typically occur within 1 to 2 hours after administration, returning to baseline within 24 hours. As with any medication that causes QTc elongation, there is a concern for Torsade de Pointes and other arrhythmias. Serotonin Syndrome is an additional risk as well occurring in less than 1% of all administration. WHAT ARE THE BENEFITS OF TAKING PART IN THE DNP PROJECT? Obtaining knowledge on an additional intervention that can reduce spinal-induced hypotension and bradycardia. WILL I BE PAID FOR PARTICIPATION? You will not be paid for participating in this project. WILL IT COST ME ANYTHING TO PARTICIPATE? There is no cost to you for taking part in this project. HOW WILL MY INFORMATION BE USED? The project team will collect information about your lower extremity total joint arthroplasty under spinal-anesthetic cases from your patients medical records. Your identity will be confidential as a data pull conducted from IU Health will exclude any names, dates, times, MRNs, or other identifiable information from yourself or your patients. Pre and posttest information will be used to assess if knowledge was obtained and/or improved upon from the educational presentation. The information released and used for this project will include: Data collection from the retrospective chart review. It only observes if and when ondansetron (Zofran) was given during the surgical procedure. The following individuals and organizations may receive or use your identifiable information: The DNP team conducting the DNP Project The Institutional Review Boards (IRB) or its designees that review this DNP Project Indiana University US or foreign governments or agencies as required by law Information collected for this DNP Project may be used for other projects or shared with other researchers for future research. If this happens, information that could identify you, such as ONDANSETRON PRIOR TO SPINAL ANESTHESIA 56 your name and other identifiers, will be removed before any information or specimens are shared. Since identifying information will be removed, we will not ask for your additional consent Electronic data from the project is being kept electronically for minimum 2 years and maximum of 5 years. The project data is protect by a password on Qualtrics Online Survey Software. The data has a second layer of protection by also having a password on my personal computer. These two passwords are not the same. HOW WILL MY INFORMATION BE PROTECTED? Every effort will be made to keep your personal information confidential, but we cannot guarantee absolute confidentiality. No information which could identify you will be shared in publications about this DNP Project. Your personal information may be shared outside the DNP Project if required by law and/or to individuals or organizations that oversee the conduct of research studies and these individuals or organizations may not be held to the same legal privacy standards as are doctors and hospitals. WHO SHOULD I CALL WITH QUESTIONS OR PROBLEMS? For questions about the project, or in the event of an emergency contact the Co-Investigator, Cody Brandes at (812-907-0183) WHAT IF I DO NOT PARTICIPATE OR CHANGE MY MIND? After reviewing this form and having your questions answered, you may decide to sign this form and participate in the DNP Project. Or, you may choose not to participate in the DNP Project. This decision is up to you. If you choose not to participate in this project or change your mind after signing this document, it will not affect your relationship with IU Health. If you change your mind and decide to leave the DNP Project in the future, the DNP Project team will help you withdraw from the DNP Project. If you choose to withdraw your authorization for use and disclosure of your protected health information, you must do so in writing by notifying Cody Brandes at Cbrandes690@marian.edu. If you withdraw your authorization, you will not be able to continue in this DNP Project. However, even if you cancel this authorization, the project team, may still use information about you that was collected as part of the project between the date you signed this document and the date you cancelled this authorization. This is to protect the quality of the project results. Otherwise, this authorization remains valid until the project ends and required retrospective chart review has been completed. ONDANSETRON PRIOR TO SPINAL ANESTHESIA 57 PARTICIPANTS CONSENT In consideration of all of the above, I agree to participate in this DNP Project. I will be given a copy of this document to keep for my records. Participants Printed Name: ______________________________________________________________________________ Participants Signature:_________________________________________________Date:________________ Printed Name of Person Obtaining Consent:______________________________________________________________________ Signature of Person Obtaining Consent: ___________________________________Date:______________________________________ 58 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Appendix G Literature Review Matrix Reference Research Design & Level of Evidence Purpose / Aim Population / Sample Variables Instruments / data collection Results Chooi, C., Cox, J. J., Lumb, R. S., Middleton, P., Chemali, M., Emmett, R. S., Simmons, S. W., & Cyna, A. M. (2020, July 1). Techniques for preventing hypotension during spinal anaesthesia for caesarean section. The Cochrane Database of Systematic Reviews. Retrieved December 5, 2022, from https://www.nc bi.nlm.nih.gov/ pmc/articles/P MC7387232/ Level 2 RCT to assess the effects of prophylactic interventions for hypotension following spinal anaesthesia for caesarean section included 125 studies involving 9469 women intravenous fluids, pharmacological interventions, and physical interventions, placebos, While interventions such as crystalloids, colloids, ephedrine, phenylephrine, ondansetron, or lower leg compression can reduce the incidence of hypotension, none have been shown to eliminate the need to treat maternal hypotension A form to extract data. For eligible studies, at least two review authors extracted the data using the agreed form. They resolved discrepancies through discussion or, if required, consulted a third person. They entered data into Review Manager 5 software (RevMan 5) and checked for accuracy (RevMan 2014) Ondansetron versus control ondansetron administration was more effective than control (placebo saline) for preventing hypotension requiring treatment (average RR 0.67, 95% CI 0.54 to 0.83 59 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Fabrcio T. M., Luis Jr. C. C, Rafaela C. G., Arajo, d. E. C. (2021). Effect of ondansetron on spinal anesthesiainduced hypotension in nonobstetric surgeries: a randomised, double-blind and placebocontrolled trial. Brazilian Journal of Anesthesiolog y (English Edition), 71(3) p.233240, ISSN 0104-0014, https://doi.org /10.1016/j.bja ne.2020.12.0 28.(https://w ww.sciencedi rect.com/scie nce/article/pii /S010400142 1001019) Farid, Z., Mushtaq, R., Ashraf, S., & Zaeem, K. (2016). Level 2 randomized, double-blind and placebo-controlled trial. compare the effect of ondansetron and placebo before spinal block on the incidence of hypotension in patients having non-obstetric surgeries. total of 144 patients scheduled for nonobstetric surgeries with an indication for spinal anesthesia were randomized. Patients received intravenous ondansetron (8 mg) or placebo before standard spinal anesthesia. Patients habitus (weight, height), resting HR, BP, 02, procedure time, opioid use prior to procedure, multiple pregnancies, or first pregnancy, time between blocks, age Patient controlled anesthesia (PCA) records when administered rescue from breakthrough pain, numeric rating scale for pain scores, electrical medical record for recording times of medication administered Hypotension occurred in 20 of 72 patients (27.8%) in the ondansetron group and in 36 of 72 patients (50%) in the placebo group (Odds Ratio OR = 0.38; 95% Confidence IntervalCI 0.19 to 0.77; p = 0.007). Fewer patients in the ondansetron group required ephedrine c ompared to the placebo group (13.9% vs. 27.8%; OR = 0.42; 95% CI 0.18 to 0.98; p = 0.04). Exploratory analyses revealed that ondansetron may be more effective than placebo in patients aged 60 years or older (OR = 0.12; 95% CI 0.03 to 0.48; p = 0.03). No difference in heart rate variations was observed. Level 2 RCT To compare the efficacy of crystalloid preloading and co-loading for prevention of A total of 74 patients (37 in each group) were included in this Standard monitors pulse oximetery and electrocardiogram were attached. All the information was documented and collected through a proforma. All the data were entered in SPSS version 17 Overall hypotension was noted in 23 patients (62.2%) of group-P and 18 60 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Comparative efficacy of crystalloid preloading and coloading to prevent spinal anesthesia induced hypotension in elective caesarean section. Pakistan Journal of Medical & Health Sciences. Retrieved January 9, 2023 from https://pjmhs online.com/2 016/jan_marc h/pdf/42%20 %20%20Com parative%20E fficacy%20of %20Crystallo id%20Preload ing%20and% 20CoLoading%20t o%20Prevent %20Spinal% 20Anesthesia %20Induced %20Hypotens ion%20In%2 0Elective%20 hypotension during spinal anesthesia for elective caesarean section. study. Patients with ASA classification 1 & 2, aged 18-40 years were included. Measured baseline mean arterial pressure (MAP) by noninvasive blood pressure (NIBP) technique before given preload or co- -P received 15ml/kg Hartmanns solution (lactated Ringers solution), 20 min before administration of spinal anesthesia. Co-load group-C received bolus of 15 ml/kg Hartmanns solution at time of administration of spinal anesthesia. Spinal anesthesia 0.75% hyperbaric 1.6ml bupivacaine Mean Arterial Pressure (MAP) was measured after spinal anesthesia at 1 minute interval till 3 minutes, then at 5 minutes and again at 10 minutes by NIBP. Reduction of MAP at least 20% was treated by vasopressor (ephedrine or phenylephrine) and analyzed using its statistical package. Mean standard deviation was calculated for quantitative variables like age, systolic blood pressure, diastolic blood pressure, and MAP at baseline then follow up at 1 minute till 3 minutes, then at 5 minutes and 10 minutes following spinal anesthesia. patients (48.6%) of group-C. The difference between two groups was statistically insignificant (p=0.242). group-P and in 20 patients (54.1%) of group-C, at 3 minutes in 21 patients (56.8%) of group-P and in 22 patients (59.5%) of group-C, at 5 minutes in 15 patients (40.5%) of group-P and in 16 patients 43.2%) of group-C, at 10 minutes in 11 patients (29.7%) of group-P and in 5 patients (13.5%) of group-C hypotension was developed 61 ONDANSETRON PRIOR TO SPINAL ANESTHESIA C%20Section .pdf Hofhuizen, C., Lemson, J., Snoeck, M., & Scheffer, G.-J. (2019, March 4). Spinal anesthesiainduced hypotension is caused by a decrease in stroke volume in elderly patients. Local and Regional Anesthesia. Retrieved December 3, 2022, from https://www.nc bi.nlm.nih.gov/ pmc/articles/P MC6404676/ Level 3, prospective cohort study Hou, M. X., Chen, J.Y., Lai, L., Liu, k., & Shen, H. Q. (2022, December 19). Ondansetron reduces the incidence of hypotension Level 1, Metaanalysis and systematic review review the mechanisms responsible for spinal anesthesia-induced hypotension (SAIH) as well as to discuss the different approaches to prevent and treat SAIH. They conducted this systemic review and meta-analysis using trial sequential analysis (TSA) to investigate whether ondansetron prevents hypotension following spinal anaesthesia. his prospective cohort study included 64 patients aged >65 years scheduled for procedures under SA; the patients received either 15 mg bupivacaine (the medium dose [MD] group) or 10 mg bupivacaine and 5 g sufentani ABP, CO, SA, SV, dosage of ephedrine and phenylephrine, map In total, 25 RCTs comprising 2536 patients (1405 patients in the ondansetron group and 1131 patients in the control group) were analyzed. Type of surgery, sample size, spinal anesthetic, dosage, time of medication (ondansetron and ephedrine) given, vasopressor use, Heart rate A MedCalc software package (MedCalc Software, Ostend, Belgium) was used for statistical analysis. Patient Local and Regional Anesthesia 2019:12 characteristics are expressed as mean and range, and hemodynamic data as mean and SD. Assumption of normality was checked using a KolmogorovSmirnov test. To compare demographic and hemodynamic data from baseline Students t-test, chi-squared test, and one-way ANOVA were used. P<0.05 was considered statistically significant. The meta-analysis was performed using the Review Manager 5.3 (version 5.3, Copenhagen, Denmark) statistical software and Stata version 12.0 (Stata Corp LP, College Station, TX, USA). The pooled risk ratio (RR) and 95% confidence intervals (CIs) for mean dosage of ephedrine was 7.8 mg in the MD group and 4.7 mg in the LD group (P=0.14). Three patients in the MD group required rescue medication (phenylephrine) to maintain blood pressure, no patients in the LD group had hypotension unresponsive to ephedrine. Baseline hemodynamic values did not differ between patients who did and did not require ephedrine (Table 5). Changes in blood pressure, HR, and CO were not influenced by height block or dose meta-analysis demonstrated that ondansetron reduces the occurrence of hypotension as compared to the control group, with high heterogeneity (RR = 0.65, 95% CI 62 ONDANSETRON PRIOR TO SPINAL ANESTHESIA after spinal anaesthesia: A systematic review and meta-analysis. Pharmaceutical s. 15(12). Retrieved January 22, 2023 from https://www.m dpi.com/14248247/15/12/158 8 dichotomous outcomes were calculated. For continuous data, the mean differences (MD) and 95% CIs were evaluated. Statistical significance was considered to be achieved when the p-value was <0.05. The heterogeneity in the trials was examined utilizing the I2 statistic, wherein I2 > 50% was defined as highly heterogeneous. Clinical and methodological issues were shown to be the primary causes for high clinical heterogeneity. Consequently, a random-effects model was utilized even in studies with low I2 values. 0.530.80, p < 0.01, I2 = 64% Subgroup analyses were performed according to the different dosages of ondansetron (4 mg vs. >4 mg) and type of surgeries (caesarean section vs. non-caesarean section). Funnel plots and Eggers test were employed to assess the publication bias. In addition, a sensitivity analysis was performed to test the stability of the primary outcome. ondansetron significantly reduced the number of patients who required vasopressor administration following spinal anaesthesia, with low heterogeneity (RR = 0.50, 95% CI 0.380.67, p < 0.01, I2 = 38% Using TSA software (version 0.9.5.10 beta), they performed a TSA method to control the risk of type I error caused by repeated testing. When the cumulative z-curve crosses the TSA monitoring boundary or enters the required information The result revealed that patients in the ondansetron group had a lower dose of administered ephedrine, with high heterogeneity (MD = 2.81 mg, 95% CI Eighteen trials recorded the incidence of bradycardia. The forest plot demonstrated that patients treated with ondansetron had a significantly lower occurrence of bradycardia, with low heterogeneity (RR = 0.56, 95% CI 0.380.83, p < 0.01, I2 = 8 63 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Kannan, H., Heggeri, M., V., & Kumaran M. R. (2022). Ondansetron attenuates hypotension due to subarachnoid block- A randomised double blind, placebocontrolled study. Journal of Research in Medical and Dental Science. 10(1). 414-420. Retrieved January 23, 2023 from https://www.jr mds.in/articles/ ondansetronattenuateshypotensiondue-tosubarachnoidblockarandomiseddouble-blindplacebocontroll Level 2, double blind placebo controlled study to test the hypothesis that ondansetron attenuates the arterial hypotension and bradycardia produced due to subarachnoid block. A randomized double blind, placebo-controlled study was performed on 60 patient Ondansetron dose, SBP, DBP, MAP HR, subarachnoid block, NIMBD, NaCl, 3mL of 0.5% hyperbaric bupivacaine, The statistical analysis was performed by STATA 11.1 (College Station TX USA) Student-test were performed to assess the significant difference between the age, height, weight, BMI, level of spinal blockade, blood pressure, and heart rate with the groups. Students paired t-test was used to assess the significance difference between the pre and post comparisons of heart rate and blood pressures. Continuous variables were expressed as mean and standard deviation; Categorical variables were expressed as frequency and percentage. P<0.05 considered as size line, no further study is required [15]. The risk of type 1 error was set as 5% with twosided, and the power was 80%. [4.72, 0.89], p < 0.05, I2 = 77 The statistical analysis was performed by STATA 11.1 (College Station TX USA) Student-test were performed to assess the significant difference between the age, height, weight, BMI, level of spinal blockade, blood pressure, and heart rate with the groups. Students pared t-test was used to assess the significance difference between the pre and post comparisons of heart rate and blood pressures. Continuous variables were expressed as mean and standard deviation; Categorical variables were expressed as frequency and percentage. P<0.05 considered as statistically significance. The attenuation in fall of heart rate was not significant with p=0.84. The attenuation in fall of SBP was not significant in study group at 10 minute interval with p=0.24 but significant at 15 and 20 minutes with p <0.05. Fall in the diastolic blood pressure at 5th, 10th 15th and 20th minute. Comparison of DBP between case and control group as compared to their baseline studies. Fall in the DBP at 5th, 10th 15th and 20th minute. P value <0.05 (except at 10 minutes) comparison of diastolic blood pressure between case and control group as compared to. their baseline studies showed significant attenuation of BP fall (p<0.05) except 64 ONDANSETRON PRIOR TO SPINAL ANESTHESIA ed-study89057.html Moro, E. T., Ferreira, M. A. T., Gonalves, R. dos S., Vargas, R. C., Calil, S. J., Soranz, M. A., & Bloomstone, J. (2020, May 20). The quality of recovery after dexamethasone, ondansetron, or placebo administration in patients undergoing lower limbs orthopedic surgery under spinal anesthesia using statistically significance Level 2, Randomized control trial To evaluate, as a primary outcome, the quality of recovery, using the Quality of Recovery Questionnaire in patients undergoing lower extremity orthopedic surgery under spinal anesthesia using intrathecal morphine (0.1 mg) and receiving either ondansetron, dexamethasone, or placebo. They also evaluate postoperative pain scores; the incidence of nausea, vomiting, pruritus, and urinary retention; use of analgesics; and PACU length of stay. One hundred and thirty-five patients undergoing lower extremity orthopedic surgery under spinal anesthesia using bupivacaine and morphine were randomly assigned to receive IV dexamethasone, ondansetron, or saline dexamethasone), O (ondansetron), and P (saline). Bupivacaine, level of spinal anesthetic inserted, surgery duration, fluid solution, age, gender, physical status, and surgical duration were recorded. During PACU stay, clinical recovery variables such as pain score, analgesic use, occurrence of nausea, vomiting, pruritus, urinary retention, and PACU length of stay (time to Aldrete score 9) were assessed. at 10 min (p=0.13) Mean arterial pressure among case and control group, shows significant attenuation of BP fall in case group (p<0.05) showing the effect of ondansetron in attenuation of BP fall by spinal anesthesia to be significant when compared to placebo The ShapiroWilk test was used to test the hypothesis of a normal distribution. Ordinal and continuous data that were not normally distributed are presented as median and range and were compared using the KruskalWallis test. Dunns multiple comparisons test was used to compare groups whenever a difference was detected. Multiple comparisons were tested at a 1.67% level (Bonferroni comparison). Statistical significance ( value) was assessed by means of a twotailed test in all instances; values below 0.05 were considered statistically significant. Statistical analysis was performed using O IBM SPSS Statistics, version 22. In patients undergoing total hip arthroplasty under spinal anesthesia using morphine 0.1 mg, postoperative pain scores were similar to those in patients who received 0.2 mg. However, higher doses were associated with greater rates of side effects including hypotension 65 ONDANSETRON PRIOR TO SPINAL ANESTHESIA intrathecal morphine. A randomized controlled trial. Anesthesiology Research and Practice. Retrieved December 4, 2022, from https://www.hi ndawi.com/jour nals/arp/2020/9 265698/ Perlas, A., Chan, V. W. S., & Beattie, S. (2016, October 1). Anesthesia technique and mortality after total hip or knee arthroplasty: A retrospective, propensity scorematched cohort study. American Society of Anesthesiologis ts. Retrieved October 24, 2022, from https://pubs.asa hq.org/anesthes iology/article/1 25/4/724/19629 Level 3, A retrospective, propensity scorematched cohort study evaluates the effect of anesthetic technique on a 30-day mortality after total hip or knee arthroplasty. identified 10,868 patients, of whom 8,553 had spinal anesthesia and 2,315 had general anesthesia. General anesthetic, with propofol with or without muscle relaxation, inhalational agents (isoflurane, desflurane, or sevoflurane). Spinal anesthesia with bupivacaine 12.5-15 mg with or without 100 mcg of morphine administered with midazolam and propofol for conscious sedation intrathecally. Preoperative thromboprophylaxis with low-molecular weight heparins TXA 3g, addition, patients undergoing TKA between 2003 and February 2012 received a continuous Bivariate tests were initially used to compare the characteristics of patients who had spinal anesthesia versus those who had general anesthesia (Mann Whitney U test, chi-square test, and Fisher exact test). To reduce the impact of treatment-selection bias on study outcomes, they used propensity scorematchedpair analyses to determine the adjusted association of spinal anesthesia with the primary (30day mortality) and secondary outcomes. In the matched cohort the 30 day mortality rate was 0.19% (n = 4) in the spinal anesthesia group and 0.8% (n = 17) in the general anesthesia group (risk ration, 0.42; 95% CI, 0.21 to 0.83; p = 0.0045). Spinal anesthesia was also associated with shorter hospital length of stay (5.7 vs 6.6 days; p < 0.001). 66 ONDANSETRON PRIOR TO SPINAL ANESTHESIA /AnesthesiaTechnique-andMortality-afterTotal-Hip Salama K. A., Goma, M. H., & Hamid, A. M. B. (2016, March 17). Fluid preloading versus ephedrine in the management of spinal anesthesiainduced hypotension in parturients undergoing cesarean delivery; A comparative study. Ains Shams Journal of femoral perineural infusion of 0.2% ropivacaine at 5 to 10 ml/h for 48 to 72 h. After February 2012, TKA patients received an adductor canal block with 20 ml of 0.5% ropivacaine followed by intraoperative local infiltration of the joint with 300 mg of ropivacaine, 30 mg of ketorolac, and 0.6 mg of epinephrine. Level 3, Retrospective comparative study The objective of the study was to compare the two therapeutic modalities, fluid preloading and ephedrine, in the management of spinal anesthesia-induced hypotension in parturients undergoing elective cesarean delivery. A total of 50 ASA III parturient women who presented for cesarean section under spinal anesthesia were enrolled in this study. They were randomly assigned into two groups: the F group (n = 25) (the fluid preloading group), which received 15 ml/kg of lactated Ringer's solution 10 min before spinal anesthesia, and the E group (n = 25) (the ephedrine group), ASA status, hemodynamics, IV fluid, level of block, ephedrine, systolic blood pressure, heart rate Obtained data were presented as mean SD or median and interquartile range (interquartile range) or count and percentage, as appropriate. Comparisons were made using Student's t-test, the 2 -test, or analysis of variance according to type of variance. Data were analyzed using computer package SPSS (version 20, 2012; SPSS Inc., Chicago, Illinois, USA) and Microsoft Excel 2013. A P value of 0.05 or less was considered statistically significant. Sample size was calculated based on a previous study. Assuming an -error of 0.05 and There was no statistically significant difference between the two groups as regards demographic data (age, weight, height, ASA physical status, and parity) and duration of anesthesia SBP was higher in the E group than in the F group; however, the results were not statistically significant, except at 4 and 22 min after spinal anesthesia 67 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Anesthesiology. 9(1), 72-75. Retrieved January 22, 2023 from http://www.asja .eg.net/article.a sp?issn=16877934;year=201 6;volume=9;iss ue=1;spage=72; epage=75;aulas t=Salama power of study 80%, a minimum of 50 participants (25 in each arm) was calculated as the sample size. HR was higher in the E group than in the F group; however, it was not statistically significant With regard to the incidence of complications, the incidence of hypotension was significantly higher in the F group than in the E group; the incidence of nausea and vomiting was higher in the F group than in the E group, but it was not statistically significant, and there were no chest symptoms in both groups The number of boluses of ephedrine required to correct hypotension was significantly lower in the E group (the ephedrine group) than in the F group (the fluid preloading group) As regards oxygen saturation, there was no significant 68 ONDANSETRON PRIOR TO SPINAL ANESTHESIA difference between the two groups Tubog, D. T., & Bramble, S. R. (2022, March). Ondansetron reduces the incidence of hypotension after spinal anaesthesia in noncaesarean delivery: A systematic review and metaanalysis. Journal of Perioperative Practice. 32(3). 29-40. Retrieved January 22, 2023 from https://journal s-sagepubcom.forward. marian.edu/d oi/epub/10.11 77/17504589 20964157 Level 1; systematic review and metaanalysis The primary aim of this review was to examine and evaluate if the use of ondansetron as a preventive intervention is effective in reducing the incidence of SIH in elective non-caesarean surgeries. 13 meta-analysis comprising of 1166 participants Using a piloted template, data were independently extracted, and discussion resolved differences of opinion. demographics of the study, randomization and outcome assessment, sample size, the number of events both in experimental and control arm and all relevant outcomes. evaluated each RCT for methodological quality according to the guidelines recommended by the Cochrane Handbook for Systematic Reviews of Intervention (Higgins & Green 2011). The six domains assessed were random sequence generation, allocation concealment, blinding of participants, personnel and outcome assessors, incomplete outcome data, selective reporting and other sources of bias. Review Manager (RevMan 5.3; The Nordic Cochrane Centre, Copenhagen, Denmark) was used for the meta-analysis (Review Manager 2014). For binary dichotomous outcomes, effect sizes were expressed by calculating pooled risk ratio (RR) with 95% confidence interval (CI) using the Mantel-Haenszel method with random-effects model. For continuous variables, results were reported as a mean difference (MD) using inverse variance with random-effects model. Random-effects model was used expecting considerable heterogeneity and afford conservative estimates. The criterion for statistical significance was p val ues < 0.05. In RCTs reporting the median and range (or interquartile range), the mean and standard deviation (SD) were calculated using the statistical algorithms proposed by Wan et al (2014). Based on the recommendations by the Cochrane Handbook for Systematic Reviews of Intervention, they considered heterogeneity between studies if analysis of 13 RCTs showed that patients treated with ondansetron experienced fewer episodes of hypotension compared to placebo (RR 0.62, 95% CI 0.44 to 0.87; p = 0.005 Eleven studies, comprising 984 patients, reported the incidence of bradycardia When compared to placebo, ondansetron reduced the incidence of bradycardia by 46% There was no statistical difference between ondansetron and placebo in the MAP at 5 and 10 minutes after spinal induction Pool estimates of these two studies showed that patients who received ondansetron have higher SAP 69 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Tubog, D. T., Kane, D. T., Pugh, A. M. (2017). Effects on ondansetron on attenuating spinal anesthesiainduced hypotension and bradycardia in obstetric and nonobstetric subjects: A systematic review and meta-analysis .AANA. Retrieved October 24, 2022, from Level 1 a systematic review and metaanalysis conduct a comprehensive meta-analysis of randomized controlled trials (RCTs) using intravenous (IV) ondansetron in reducing the incidence of hypotension and bradycardia associated with spinal anesthesia. of the 15,687 patients, 80.1% had GA, 13.1 had a combination of GA and NA, and 6.8 had only NA. The overall quality of the findings was assessed using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach (Ryan & Hill 2016). The GRADE approach rates the findings as high, moderate, low , or very low. the I2 statistics has values > 50% and a p value of <.01 number and age range of participants, ASA physical status classification of patients, definitions of hypotension and bradycardia, outcomes observed, rescue drugs used in the advent of hypotension (ephedrine, 5, 6, 10 mg; phenylephrine, 20, 50, 100 g) and bradycardia (atropine, 0.1, 0.3, 0.5 mg; glycopyrrolate, 0.2 mg; ephedrine, 25 mg), types of local anesthetic, baricites and dosages, timing of fluid hydration (preloading and coloading), type and amount of fluid used Review Manager (RevMan 5.3)15 for meta-analysis. They compared to those patients with placebo at all four time points Fewer patients in the ondansetron group received rescue ephedrine compared to the control group (RR 0.61, 95% CI 0.43 to 0.87; p = 0.007). estimated the effects of ondansetron on the incidence of SIH and bradycardia by calculating pooled risk ratio (RR) with the 95% confidence interval (CI). For continuous variables, results were reported as a mean difference. The random-effects model for analysis was used, because they anticipated significant methodologic and clinical heterogeneity of data results. The criterion for statistical significance was P < .05. Four trials26-29 in the non- obstetric setting investigated the administration of IV ondansetron before spinal anesthesia. The pooled analysis revealed that pretreatment of IV ondansetron was not associated with a decrease in the incidence of SIH (RR, 0.45; CI, 0.121.66). The results showed a small effect size and large heterogeneity (I2 = 83%). Ondansetron by Dose. Eight 70 ONDANSETRON PRIOR TO SPINAL ANESTHESIA https://www.a ana.com/docs /defaultsource/aanajournal-webdocuments1/effectsondansetron0417-pp113122.pdf?sfvrs n=8dd448b1_ 6 Terkawi, A. S. , Mavridis, D. , Flood, P. , Wetterslev, J. , Terkawi, R. S. , Bin Abdulhak, A. A. , Nunemaker, loading, and the level of the sensory blockade. The dose of IV ondansetron and the timing of its administration RCTs17-22,24,29 investigated the use of 4 mg of ondansetron compared with placebo. Of these, 1 study29 compared ondansetron with ramosetron. When combining data, regardless of the type of drugs in the control group, metaanalysis results showed reduction in SIH (RR, 0.57; CI, 0.35-0.93). However, pooled data from the 7 studies comparing ondansetron with placebo showed a higher reduction (22%) in the risks of hypotension compared with placebo (RR, 0.49; CI, 0.31-0.78). Level 1, Metaanalysis, Metaregression and trial sequential analysis Disagreement among many underpowered studies has led to an equivocal understanding of the efficacy of the 5HT3 antagonist ondansetron in preventing the consequences of fourteen randomized placebo-controlled trials (1,045 subjects) were identified and analyzed. By using conventional metaanalyses, the authors determined that authors, year of publication, type of surgery, subarachnoid drug, definition of hypotension, hemodynamic monitoring method, preventative measures, incidence of used the (1) Review Manager (RevMan) [Computer program], version 5.3 (The Nordic Cochrane Centre, The Cochrane Collaboration, Denmark, 2014) for the meta-analyses; (2) STATA version 13.0 (STATA Corp., USA) for the metaregression and publication bias according to metaanalysis using traditional methods, the estimated effect of ondansetron on the incidence of hypotension showed a statistically significant 71 ONDANSETRON PRIOR TO SPINAL ANESTHESIA M. S. & Tiouririne, M. (2016). Does ondansetron Modify Sympathecto my Due to Subarachnoid Anesthesia?. Anesthesiolog y, 124 (4), 8 46-869. doi: 10.1097/ALN .0000000000 001039 Retrieved December 1, 2022 from https://oceovidcom.forward. marian.edu/ar ticle/0000054 2-20160400000024/HTML Xiao, F., Wei, C., Chang, X., Zhang, Y., Xue, L., Shen, H., Ngan K., Warwick, D., & Chen, X. (2020). A prospective, randomized, double-blinded study of the Level 2, randomized double blind study sympathectomy after subarachnoid anesthesia. The authors assessed the efficacy of ondansetron with respect to the overall quality and statistical power of the meta-analyses ondansetron was associated with reduction in the incidence of hypotension hypotension and bradycardia, and amount of vasopressor (phenylephrine and ephedrine) consumed. analyses; (3) the GDT software for developing the GRADE (McMaster University and Evidence Prime Inc., Canada); and (4) OpenBUGS release 2.3.2 (Cambridge Institute of Public Health, United Kingdom) for selection bias; and finally (5) the TSA software version 0.9 beta (Copenhagen Trial Unit, Denmark), 2011, for TSAs. preventive effect (RR = 0.62 [95% CI, 0.46 to 0.83]; P = 0.001) determined the effective dose in 50% of subjects (ED50) of a prophylactic phenylephrine infusion for preventing hypotension in patients who received a single dose of intravenous ondansetron 4 mg or saline control before combined spinal epidural anesthesia for Sixty parturients were randomly assigned to receive ondansetron (group O) or saline control (group C) 10 minutes before positioning for induction of spinal anesthesia. Vasopressor requirements, 4mg of ondansetron or saline control, blood pressure, HR, combined spinal epidural, For continuous variables, the KolmogorovSmirnov test was used to test normality of distribution. Normally distributed variables were presented as mean standard deviation (SD) and were analyzed using Student t test. Non-normally distributed variables were presented as median and interquartile range (IQR) and were analyzed using The ED50 of the rate of intravenous phenylephrine infusion was lower in group O (0.24 g/kg/min [95% CI, 00.100.38 g/kg/min]) compared with group C (0.32 g/kg/min [95% CI, 0.140.47 72 ONDANSETRON PRIOR TO SPINAL ANESTHESIA effect of intravenous ondansetron on the effective dose in 50% of subjects of prophylactic phenylephrine infusions for preventing spinal anesthesiainduced hypotension during cesarean delivery. Anesthesia & Analgesia. 131(2). 564569. Retrieved January 23, 2023 from https://journals. lww.com/anest hesiaanalgesia/Fullte xt/2020/08000/ A_Prospective, _Randomized,_ Double_Blinde d_Study_of.34. aspx Zhong, H., Wang, Y., Wang, Y., & Wang, B. (2019, June). Compari son of the elective cesarean delivery. Level 3, cohort study analyzed the effect and clinical value of the general anesthesia and the combined spinalepidural anesthesia in elderly patients 50 patients in the study group who received combined spinal- epidural anesthesia by ondansetron combined spinalepidural anesthesia by ondansetron hydrochloride tablets combined with spinalepidural puncture kit, the Mann-Whitney U test. Categorical variables were presented as number (%) and were analyzed using the 2 test. The 95% confidence interval (CI) and standard error for ED50 values were estimated using the method described by Choi values for the 2 groups was assessed by calculation of relative mean potency with 95% CI between groups. GraphPad Prism version 5.0 (GraphPad Software Inc, San Diego, CA) and IBM SPSS Statistics for Windows version 22.0 (IBM Corp, Armonk, NY) were used for data analysis. P values <.05 were considered statistically significant. g/kg/min]) (P < .001). The ED50 values calculated using regression were 0.21 g/kg/min (95% CI, 0.180.24 g/kg/min) in group O and 0.29 g/kg/min (95% CI, 00.250.32 g/kg/min) in group C. The estimate of relative median potency for phenylephrine in group O versus group C was 0.74 (95% CI, 0.37 0.95). Dose response curves for the rate of phenylephrine infusion for preventing hypotension derived from probit regression analysis are shown i The data were analyzed and processed using SPSS 19.6 statistical software [Boyi (Beijing) Information Technology Co., Ltd., Beijing, China]. The patient's basic the heart rate, systolic blood pressure, and diastolic blood pressure index 15 min before the end 73 ONDANSETRON PRIOR TO SPINAL ANESTHESIA effect and clinical value in general anesthesia and combined spinal-epidural anesthesia in elderly patients undergoing hip arthroplasty. Experimental and Therapeutic Medicine. Retrieved December 4, 2022, from https://www.nc bi.nlm.nih.gov/ pmc/articles/P MC6489064/ Zhou, C., Zhu, Y., Bao, Z., Wang, X., & Liu, Q. (2018). Efficacy of ondansetron for spinal anesthesia during cesarean section: a meta-analysis of randomized trials. The Journal of undergoing hip arthroplasty. hydrochloride tablets combined with spinal-epidural puncture kit, and 56 patients in the control group who received general anesthesia by fastinduced endotracheal intubation. sex, age, BMI, HR, BP, alcohol and smoking enumeration data was expressed as a percentage [n (%)] and analyzed by the Chi-square test of the operation in the study group were significantly higher than that of the control group, and the difference was statistically significant (P<0.05) (Table III Maternal side effects, including hypotension, nausea/vomiting, and shivering, were compared between the ondansetron and placebo groups. ondansetron dose, A meta-analysis was performed via using RevMan 5.2 provided by the Cochrane Collaboration. Enumeration data were presented as relative risk (RR) or odds ratio (OR) with a 95% confidence interval (CI). Measurement data were expressed as the mean difference (MD) with a 95% CI. A total of 7 RCTs, with 449 people, were included in the study. Bradycardia triggered by spinal anesthesia during cesarean section was reported. The metaanalysis results of the fixed-effects model showed that the incidence of brady- cardia in the ondansetron group was (n=106) Level 1: Metaanalysis of RCTS To investigate the efficacy and safety of ondansetron during cesarean section under spinal anesthesia 21 RCTs were included in this study. (n = 1872) ONDANSETRON PRIOR TO SPINAL ANESTHESIA International Medical Research, 46( 2), 654662. https://doi.org /10.1177/030 00605177165 02 74 statistically significantly lower than that in the placebo group [RR 14 0.45, 95% CI (0.26, 0.80), P 14 0.006  ...

... Microlearning Effect on Patient Temperatures 1 Microlearning Effect on Patient Temperatures 2 Table of Contents Abstract 3 Introduction 4 Background 5 Problem Statement 6 Organizational Gap Analysis of Project Site 6-7 Review of the Literature 8-9 Conceptual Framework 10 Goals/Objectives/Expected Outcomes 11 Project Design/Methods Project Site and Populations 12 Measurement Instruments 13 Data Collection Procedures 13 Ethical Considerations/Protection of Human Subjects 14 Data Analysis and Results 15-16 Discussion 17 Conclusion 18-19 References 20-21 Appendices Appendix A SWOT 22 Appendix B KTA Cyle 23 Appendix C Qualtrics Q&A 24 - 25 Appendix D Pre/Post Microlearning Data Collection Template 26 Appendix E Descriptive Statistics 27 Microlearning Effect on Patient Temperatures 3 Abstract This quality improvement project investigated the impact of microlearning on perioperative staff behavior regarding maintaining optimal patient temperatures throughout the surgical process. This project also served as a targeted data collection initiative aimed at enhancing patient experience during surgery. High level performance in healthcare has become challenging often due to fatigue arising from volumes of information workers must absorb in short periods of time. Recent literature suggests that much of the knowledge derived from information consumed in bulk is minimally retained and quickly forgotten. Microlearning breaks down complex information into targeted segments and facilitates focused understanding. Microlearning involves a variety of easily accessible formats, such as mobile applications or online slide presentations that are accessible to the learner for acquiring current information, effectively refresh knowledge that has become inactive, or promote learners to function at higher levels with new perspective. One focus of the project was on assessing the level of importance staff placed on monitoring patient temperature as well as their knowledge of, and adherence to, institutional policies. The educational intervention consisted of an online presentation focused on thermoregulation during surgery and facility policy. Surveys were administered to measure staff knowledge before and after the educational intervention then analyzed via paired t-tests to measure the microlearning intervention's effectiveness on staff knowledge. The educational intervention and surveys were delivered through Qualtrics to ensure participant convenience. The second phase of this project included retrospective chart reviews to discern the impact of the microlearning intervention. To provide insight into the effectiveness of the microlearning intervention, extrapolations were performed utilizing statistical inference and physical patient temperatures before, during, and after surgery. Keywords: surgical patient warming, microlearning, patient temperature AND health Microlearning Effect on Patient Temperatures 4 Microlearning Effect on Perioperative Staff Performance Warming Surgical Patients: Using Surgical Patient Temperatures Before, During, and After Surgery This quality improvement project was submitted to the faculty of Marian University Leighton School of Nursing as partial fulfillment of degree requirements for the Doctor of Nursing Practice, Family Nurse Practitioner track. Intentions for this project was to research the effectiveness of a microlearning intervention structured to increase staff knowledge regarding surgical patient thermoregulation as well as explore the impact a microlearning intervention had on perioperative patient temperatures. Optimizing patient temperature throughout the perioperative experience is important for improved patient care outcomes. By recognizing the impact thermoregulation has on surgical outcomes and the patients' experience, institutional policies may be implemented. Hence, the issue of surgical patients experiencing coldness may become better mitigated. Patient temperature is a vital metric that is identifiable and also modifiable. Patient temperature can be influenced by a range of factors and can be positively affected through interventions implemented by perioperative staff. Such interventions include active body surface warming, temperature tracking, and minimizing unnecessary exposures that result in heat loss (Hymczak et. al., 2021). Microlearning, characterized as the segmented presentation of focused topic-based knowledge (Shail, 2019), is emerging as a powerful tool for staff development. Microlearning empowers staff with targeted knowledge and fosters informed decision-making by directing attention toward specific topics (in this case, patient warming). Such an approach is valuable in addressing information overload while encouraging continual improvement in staff performance. The chosen target population for this project comprised perioperative staff recognized as stakeholders in the management of surgical patient temperature. Additionally, a retrospective Microlearning Effect on Patient Temperatures 5 chart review of surgical patients was selected based on convenience and adherence to inclusion/exclusion criteria. Objectives of this quality improvement project included assessing staff knowledge and the efficacy of the microlearning activity in enhancing staff performance regarding the warming of surgical patients. Additionally, the impact of the learning activity on patient outcomes was assessed with the intent to determine if patient care improved in terms of thermoregulation before, during, and/or after surgery. Background Despite awareness of the importance of thermoregulation in surgical settings, the issue of patient coldness continues. Balki et al. (2020) emphasized patient coldness results in significant implications for patient satisfaction, recovery, and the prevention of adverse surgical events. In addition, they proposed that enhancing the quality of perioperative thermoregulation is an essential element in addressing factors such as patients being cold. Shockingly, estimates indicate that 50% to 90% of surgical cases involve patients experiencing hypothermia (Shail, 2019). The astonishing economic impact of a single adverse event in surgery has been likened to the cost of warming 400,000 cotton blankets (Rauch et al., 2021). This comparison helps illustrate how the cost of a simple warming measure is minuscule when considering the impact it has on patient outcomes. Microlearning has emerged as a potential solution to rapidly bring staff up to speed on evolving practices, provide knowledge refreshers, and align staff with the institutional vision. According to Haghighat et al. (2023), microlearning is effective in conveying essential knowledge as it enhances the learning process due to accessibility, applicability, user compatibility, focused content, and user satisfaction. All of which are necessary to respond to the need for effective targeted education, address the dynamic nature of healthcare, and to empower staff with the ability to develop and maintain high level decision-making skills. Microlearning Effect on Patient Temperatures 6 The microlearning survey included ten questions with one correct multiple choice scored answer for each question. The exact same questions were used for both the pre-microlearning and post-microlearning segments of the intervention. The educational aspect consisted of a PowerPoint slide presentation that delivered focused content and provided answers to the questions that were contained within the survey. Evidence- based practices, recent literature evidence and project site policy regarding perioperative thermoregulation was included in the educational intervention aspect and was to be completed after the pre-microlearning and again before the post-microlearning survey. Overall, the completion time for perioperative staff participants was estimated to be under 20 minutes. Problem Statement There is a need for staff development methods that are efficient, effective, and incentivized amidst the challenges of educating staff who are unfamiliar with the intricacies of patient care and keeping seasoned staff up to date on evidence-based innovative practices. It is most important that the impact of educational efforts be explored so institutions move beyond assessing whether or not the activity resulted in immediate increased staff knowledge and move toward gauging if the education was actually put into practice and impacted patient outcomes. The knowledge should result in improved care delivered and optimize patient outcomes. This DNP project aimed to explore the impact of a microlearning activity on staff knowledge regarding surgical patient thermoregulation, and the subsequent impact the microlearning exerted on policy adherence and surgical patient temperature outcomes. Organizational Gap Analysis of Project Site The fiscal health of healthcare organizations relies heavily on ethical reputation and reimbursement for services rendered. Both are influenced by patient outcomes and patient satisfaction. Poor patient outcomes result in increased healthcare costs. Reputation regarding Microlearning Effect on Patient Temperatures 7 quality of care influences decisions made by consumers in the competitive marketplace. The revenue an institution receives can be impacted when patient care outcomes are deemed subpar compared to other institutions for similar services. Lengthier hospital stays or hospital readmissions can also invoke punitive costs or denied payments for providers. Keeping a patient warm throughout the perioperative experience reduces the risk for poor surgical outcomes and fosters patient satisfaction (Balki et al., 2020). It is a known phenomenon that the bodys ability to regulate temperature is suppressed during surgery. Hence, it is important to employ intentional strategies to mitigate heat loss during surgery. Mitigating fluctuations of temperature during surgery is one example of how healthcare providers can positively influence patient outcomes and reimbursement for services rendered. When a standard of care is not being met or best practices are not adhered to, hospitals add policies in an effort to consistently improve skilled decision making and ensure staff avoid overlooking their role in optimizing care provided in the healthcare continuum. The process for implementing a new policy typically includes a staff in-service or professional development activity which provides an opportunity for staff to not only learn of the new policy, but also understand the rationale for the policy and its impact on patient health outcomes. Effectively incentivized education efforts are also paramount to policy implementation and ensuring expectations are met. As a part of early project planning, a basic SWOT analysis was conducted to evaluate the internal strengths and weaknesses of the site, as well as external opportunities and threats that could have an effect on the quality improvement effort. Noteworthy strengths identified include sample convenience, academic curiosity, surgical patient thermoregulation serving as an active benchmark, and the institutions recent attention toward applying microlearning for staff Microlearning Effect on Patient Temperatures 8 education efforts. These elements collectively created a conducive environment for implementation of this quality improvement project. Conversely, the identified weaknesses to this quality improvement project encompassed project constraints, scheduling conflicts, absence of a fiscal budget, and this being a nonmandatory non- incentivized microlearning activity. Despite these challenges, the project team remained committed to leveraging available resources to plan, navigate, and execute this project. Numerous potential opportunities were identified from analysis of project data. These include the future plans for extrapolations and data discovery. The insights derived from this academic quality improvement project can also serve as a valuable guide in steering future efforts and formulating successful strategies to address specific challenges regarding institutionwide quality improvement initiatives. This quality improvement project was positioned not only to address immediate concerns, but also to establish a foundational roadmap that may inform future quality improvement endeavors. Conversely, threats to the project's success were recognized, including the dynamic nature of non-mandatory staff participation, the employee turnover rate, the inherent autonomy of staff to choose whether to complete or not complete tasks amongst the sheer volume of perioperative responsibilities. Mitigation strategies were implemented to navigate these challenges. A detailed visual representation of the SWOT analysis findings is represented in Appendix A. Review of Literature In the realm of perioperative care, maintaining optimal patient temperatures during surgery is crucial for positive outcomes. hypothermia has been shown to occur in 50-90% of surgical cases (Moola & Lockwood, 2011). This phenomenon is linked to increased blood loss, extended length of stay (Rauch et al., 2021), and adverse patient outcomes (Palmer et al., 2019), Microlearning Effect on Patient Temperatures 9 highlighting the necessity for improved practices in surgical patient warming (Munday et al., 2023). Such research explores the potential of microlearning interventions to enhance perioperative staff's knowledge of patient warming in surgical settings. The integration of targeted microlearning applications into clinical workflow represents a contemporary approach to addressing a complex issue. Akbar et al. (2023) defined microlearning as technology-based small learning experiences. Microlearning involves breaking down complex topics and incrementally presenting targeted information. Recent generations have refined the definition of microlearning to include features such as accessibility, convenience, and mobility (Robles et al., 2023). Microlearning's allure lies in a 90% learner satisfaction rating and demonstrated improvements in knowledge scores (Zarshenas et al., 2022). Clinical learners prefer microlearning over traditional methods (Garber, 2020), appreciating the ability to self-pace their learning (Shail, 2019). Despite a 70% estimated usage among educators, the learner satisfaction rating remains high at 90% (Zarshenas et al., 2022). Haghighat et al. (2023) suggested microlearning as an effective model for conveying targeted concepts and maximizing learner interaction, while others emphasize the need for standards and a qualitative instrument (Akbar et al., 2023) to ensure valid foundational information (Straus et al., 2009). User friendly aspects of microlearning include learner selfautonomy and clinical performance outcomes. Validation instruments can standardize microlearning platforms(Robles et al., 2023), but face-to-face interactions and checklists (Rauch et al., 2021) are essential for application and competencies. The overarching goal of microlearning is to transition from knowledge acquisition to evidence-based actions that enhance the quality of care. Microlearning Effect on Patient Temperatures 10 Aiming to provide thermal comfort for surgical patients, patient warming has gained attention in the last decade in effort to reduce anxiety surrounding surgery (Palmer et al., 2019), and cut inadvertent costs associated with suboptimal perioperative thermoregulation (Rauch et al., 2021). Preventing thermal discomfort is multifaceted and should follow a checklist (Moola & Lockwood, 2011; Munday et al., 2023; Balki et al., 2020; Rauch et al., 2021). Active warming, such as blowing warmed air across the patient's skin, and passive warming by limiting exposure of bare skin to the elements, are strategies to mitigate the risk of hypothermia (Balki et al., 2020; Rauch et al., 2021). However, solely relying on passive warming techniques is insufficient; active body surface warming is necessary to prevent perioperative hypothermia (Rauch et al., 2021). Conceptual Framework Conceptual frameworks, like the Knowledge to Action (KTA) Framework , play a crucial role in guiding evidence implementation in practice. The KTA Framework, composed of Knowledge Creation and the Action Cycle, provides a dynamic and flexible model for translating evidence into sustainable healthcare interventions (Field et al., 2014; Straus et al., 2009 ). The concept for this scholarly project was based upon quality improvement. Microlearning is a more recent form of education generating attention from learners and e educators. The concept of quality improvement will skirt a conceptual framework based upon the Knowledge to Action (KTA) cycle which developed in the early 2000s out of Canada ( Field et al., 2014; Straus et al., 2009). Conceptual frameworks play a crucial role in guiding the implementation of evidence in practice, and the KTA Framework offers a dynamic and flexible model, consisting of Knowledge Creation and Action Cycles. The KTA framework is a vital tool in addressing the complex Microlearning Effect on Patient Temperatures 11 challenge of translating evidence into effective sustainable interventions (Field et al., 2014; Straus et al., 2009). A representation of the KTA framework is included in Appendix B. Goals, Objectives, and Expected Outcomes This quality improvement project featured a concise non-mandatory microlearning intervention delivered in PowerPoint slide format accessible to participants through management via email containing an active link. The estimated completion time for the pre/post learning knowledge survey and the brief PowerPoint learning intervention was less than 20 minutes. The overarching goal was to determine if brief, targeted learning presentations can prompt action. Perioperative staff were expected to engage in a knowledge survey which consisted of 10 multiple-choice questions. Participation was voluntary. Staff were asked to provide consent by clicking "Continue" on the first slide, which also included an active link to generic participation details. After completing the pre-microlearning survey, staff were expected to proceed to a link for the PowerPoint microlearning intervention that provided answers and insights. Following the intervention, participants were expected to click on a final link to complete a post-microlearning knowledge survey. The overall objective was to determine if breaking down complex information into targeted microlearning segments enhanced stakeholder understanding, decisionmaking, or performance. Expected outcomes regarding low overall participation is due to staff turnover rate, voluntary participation, and restrictive accesses. Microlearning intervention pre-learning scores were anticipated to exhibit minimal variance. Maintaining the same questions allowed for robustness between pre/post survey groups. Patient temperatures were not expected to significantly change; rather, the aim was to reduce fluctuations in temperatures throughout surgery. This quality improvement project addressed the established goal of tracking Microlearning Effect on Patient Temperatures 12 perioperative patient temperatures and aimed to use targeted microlearning to enhance staff knowledge, foster action, and improve patient satisfaction. Project Design and Methods Project Site & Populations The project was situated in a level-one trauma hospital in an urban midwest city, with a focus on vulnerable populations. The project site encompasses a broad spectrum of medical specialties, including inpatient, outpatient, emergency, adult burn, orthopedics, sports medicine, primary care, plastics, trauma, neurology, pulmonology, endoscopy, and oncology. Two distinct populations were expected to participate in the project: Population #1 consisted of perioperative staff on the third floor main surgery area who engaged in direct patient care within pre-operative, intra-operative, or postoperative stages. Population #2 was composed of patients meeting inclusion criteria who underwent surgery during the data collection period. Patient data, specifically temperature readings representing pre, during, and post-surgery phases, were collected through retrospective chart review. No face-to-face interaction with patients occurred, and no identifiable data was retained. Inclusion criteria for staff involved all third-floor main surgery perioperative staff, with participation / non-participation having no impact on employment or status. Surgical patient inclusion criteria encompassed surgical cases for individuals 18-65 years of age within the project site, excluding specific conditions like pregnancy, burns, trauma, police incarceration, and any surgical cases performed outside the designated main surgical area. Exclusion criteria for both populations were clearly defined to ensure data integrity. Retrospective chart reviews captured patient data, including temperature and surgery type, recorded in Fahrenheit. Perioperative staff data was electronically collected via Qualtrics Microlearning Effect on Patient Temperatures 13 software, focusing on numerical outcomes. This approach enabled comprehensive and systematic collection of relevant data for this quality improvement project. Measuring Instruments To gauge the outcomes of this quality improvement project, a custom survey was created. The survey was administered to staff participants through the project sites education department management. The self-generated survey encompassed 10 questions, each offering multiplechoice answers with one correct response, as detailed in Appendix C. More points for correct answers were awarded and less points for incorrect answers were awarded. Scores were tallied and recorded for each pre-intervention and post-intervention sample. This approach provided a quantifiable measure of the participants' knowledge survey, allowing for a comparative paired Welchs paired T-test statistical inference to assess the impact of the microlearning educational intervention. The question/answer based survey instrument served as a valuable tool in capturing both baseline and post-intervention data, enabling a comprehensive evaluation of outcomes regarding this quality improvement project. Data Collection Procedures Data collection leveraged retrospective chart reviews using the EPIC software at the project site. Surgical patient temperatures were gathered in two phases: a control block before the microlearning intervention and a variable block after the intervention, covering preoperative, intraoperative, and postoperative phases. Microlearning was electronically delivered to staff. Anonymity was ensured during response and tallying by requiring no identifiable data. Staff were to undergo a pre- and post-intervention electronic quiz with scores assigned for correct and incorrect responses, facilitating a behavior analysis. Pre-microlearning surgical patient temperatures were compared with post-microlearning temperatures, evidencing the microlearning impact on staff behavior regarding patient warming. Microlearning Effect on Patient Temperatures 14 Electronic pre-microlearning retrospective chart review preceded the educational intervention data range. The microlearning educational intervention link included pre- and post-intervention perioperative staff surveys on thermoregulation knowledge, a brief microlearning presentation, and a post-intervention survey. Targeted staff had one week for participation, followed by a brief post-intervention chart review. The entire process aims for an efficient completion time, with time allotted for data analysis. Participants' identifiable information was not requested. This streamlined process ensured efficient data collection, intervention, analysis, and dissemination. Ethical Considerations & Protection of Human Subjects Prior to initiating data collection for this DNP quality improvement project, approval was sought from the Marian University Internal Review Board (IRB). The project site waived their organizations IRB review. The official IRB Determination Form was promptly submitted upon proposal approval and review by all team members. All participants were safeguarded under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), ensuring the privacy of patients' health information according to Modifications to the 2013 HIPAA Privacy, Security, Enforcement, and Breach Notification Rules (DHHS, 2013). All information collected for evaluating project impact was devoid of potential patient identifiers. The risk to participating patients was minimal and comparable to the risks associated with receiving indirect care. Participant confidentiality was upheld through the coding of results. The list of participants and their corresponding identification numbers was securely stored on a monogamous user laptop, featuring password-protected access, and exclusively accessible to the project leader. Microlearning Effect on Patient Temperatures 15 Data Analysis & Results Data analysis for this quality improvement project entailed two statistical datasets. For dataset population #1 (perioperative staff), inferential statistical comparison was conducted on pre-intervention quiz scores and post-intervention quiz scores using Welchs paired ttest. Mishra et al. (2019), which is aligned with this project's objectives. The application of Welchs paired t-test was supported in the context of comparing the same participants in a before-and-after format. Welchs paired t-testing also addresses potential biases in the standard deviations of pre-intervention versus post-intervention quiz scores, ensuring robust analysis (Bobbitt, 2021). This statistical approach aimed to validate any discernible changes regarding whether the microlearning intervention significantly influenced perioperative staffs performance. The second layer of analysis of this quality improvement project focused on improving surgical patient perioperative care. Data for surgical patient temperature were collected for dates before and after the microlearning intervention through retrospective chart reviews. Statistical analysis compared pre-intervention and post-intervention temperatures, detecting any variations indicative of positive change in patient care outcomes at the project site. For dataset population #2 (patients undergoing surgery during the period of this quality improvement project), descriptive statistics encompassed the highest temperature, lowest temperature, average temperature, most repeated temperature, service with the highest recorded temperature, service with the lowest temperature, service with the greatest temperature change, and service with the least temperature change. Finally, data analysis revealed the percentage of cases reviewed that fell below the facility-defined hypothermia range of less than 96o F. A total of 59 surgical patient cases underwent scrutiny. Each case encompassed three distinct phases: preoperative, intraoperative, and postoperative, both before and after Microlearning Effect on Patient Temperatures 16 microlearning intervention. The pre-microlearning data analysis comprised n=28 participants, while post-microlearning analysis involved n=31 participants. Results from the perioperative staff survey yielded inconclusive outcomes due to zero full completion rate among perioperative staff. Descriptive statistics are provided in Appendix E. Statistical analysis of pre/post-microlearning data demonstrated overall p-values below .05 hence the rejection of the null hypothesis and acceptance of the alternative. It underscored the impact of raising awareness on influencing outcomes. The average pre-microlearning temperature registered at 98.1o F, whereas the post-microlearning average stood at 97.7o F. The lowest temperatures recorded were 95.9o F pre-microlearning and 94.7o F post-microlearning. In the pre-microlearning phase, one surgical case recorded temperatures below the facility policy threshold of 96.0o F, constituting 3.6% of the reviewed cases. Conversely, during the post-microlearning phase, four cases fell below the policy 96o F threshold, comprising 12.9% of cases reviewed. The overall highest temperature recorded was 100.9o F within the urology service, while the overall lowest temperature recorded was 94.7o F also in the urology service. During the post-microlearning phase the overall lowest temperature recorded was 94.7o F as well as the overall highest temperature change of 4.1o F were discovered within the Vascular service. The overall highest temperature recorded was 100.0o F found within the orthopedic service during the post-microlearning phase. Interestingly, during the premicrolearning phase the neurology service exhibited no temperature change among patients. It was the gynecological service during the post-microlearning phase with no recorded temperature change. Statistical inference was computed using Microsoft Excel. The data collection template provides an overview of project analysis in Appendix D. Microlearning Effect on Patient Temperatures 17 Discussion This quality improvement project revealed statistically significant evidence which underscored the pressing need for further research into microlearning applications. Impact made from the awareness of a metric such as thermoregulation was also highlighted. The academic inquisitive nature of the quality improvement project was the strength that overcame hurdles. The project faced obstacles including restricted access to data and staff throughout the project phases. Threats to the project encompassed the overlapping volume of in-person health fair activities staff were mandated to attend and the non-mandatory nature of the microlearning intervention. Unrestricted access to perioperative staff was not permitted. Any type of review regarding staff workflow, staff routines, checklist tracking of task completion was also not allowed. Restricted minimized access to patient charts during data collection presented challenges for this project. In addition, this non-mandatory microlearning education project gave perioperative staff access to the survey material for one week. Whereas perioperative staff typically have multiple months to complete their continuing education modules. This project intertwined the knowledge creation phase intended on determining what level of education would prompt action in attempt to illustrate how the Knowledge to Action framework consists of two distinct inter-dependent cycles designed to lead lasting change. Conversely, the second layer of utilizing perioperative staff scores to validate the effectiveness of the microlearning proved to be an encumbrance of the project. The nonmandatory nature of the microlearning made it difficult to ensure full participation concerning the microlearning survey aspects of the project. In retrospect any particular score of a subset population may not adequately gauge the effectiveness of the microlearning intervention and thus suggests that a more standardized approach may be warranted with regard to validating effectiveness of microlearning and outcomes generated after the fact. Microlearning Effect on Patient Temperatures 18 Employing a scientific method infused with academic intrigue, the project determined the significance of hypothermia at the project site and the requisite level of learning to influence patient outcomes. The use of a standardized survey instrument ensured consistent data collection and facilitated a clear analysis of this quality improvement project. There were 9.3% more patients that experienced coldness after the microlearning versus prior to the microlearning. These findings not only support the necessity for future research but also align with existing literature indicating patients' increasing experience of coldness during surgery. Microlearning has user-appeal due to aspects of convenience and autonomy. The efforts and outcome surrounding the utilizing perioperative staff substantiated the global need to move beyond determining if learning was completed and shift toward assessing knowledge application. The implications for clinical practice are profound: preventive measures against hypothermia vastly outweigh corrective actions, and hypothermia incidences are indeed prevalent. Given the demanding nature of healthcare where caregivers must absorb vast amounts of information in short periods, it becomes crucial to maintain active and frequent utilization of information and skills. Thus, having readily available resources tailored to required skill sets for on-demand review, refreshment, and retention becomes imperative. Conclusion The clinical challenge manifests as patient discomfort due to experiencing coldness during surgery. The clinical problem is the volume of information healthcare workers must digest, retain, and then ultimately perform such skills that often require ongoing routine practice to remain proficient. Bear in mind that not all skill sets are utilized on a daily basis across all healthcare settings and every person may learn differently. Microlearning and on-demand smallbatch applications are poised to drive the next frontier in healthcare, offering a solution to the challenges of knowledge retention and accessibility in the fast-paced medical landscape. Microlearning Effect on Patient Temperatures 19 Recent literature suggests that more patients are experiencing hypothermia during surgery which also aligns with data obtained at this quality improvement project site. The scope of this project was to determine the impact of microlearning on staff action using surgical patients' temperature as a gauge to determine magnitude of action created among staff. User accessibility and convenience are attractive factors for microlearning platforms. Accessibility and convenience should not outweigh confirmation and standardized validation effort. There is a metric that must be applied so that each person can receive confirmation to have received the microlearning, completed the intervention as well as transformed knowledge into adopted action. Awareness of a topic as a metric being measured may create change. Lasting change is attained through trial and error which ultimately leads to insight. This project served as an academic learning experience. The data discovered conducting this quality improvement project highlighted the importance of perioperative thermoregulation, revealed recent evidenced based materials and emphasized opportunities to improve patient outcomes at the project site. Microlearning Effect on Patient Temperatures 20 References Akbar, Z., Khan, R., Khan, H., & Yasmeen, R. (2023). Development and validation of an instrument to measure the microlearning environment of students (MLEM). BMC Medical Education, 23(1). doi:10.1186/s12909-023-04381-3 Balki, I., James Khan, P. S., Duceppe, E., Bessissow, A., Sloan, E., Morley, E., . . . Devera, P. (2020). Effect of perioperative active body surface warming systems on analgesic and clinical outcomes: A systematic review and meta-analysis of randomized controlled trials. Anesthesia Analog, 131(5), https://pubmed.ncbi.nlm.nih.gov/33079867/. doi:10.1213/ANE.0000000000005145 Field, B., Booth, A., Ilott, I., & Gerrish, K. (2014). Using the knowledge to action framework in practice: a citation analysis and systematic review. Implementation Science. Retrieved from https://implementationscience.biomedcentral.com/articles/10.1186/s13012-014-0172-2 Garber, A. (2020). Flipping Out! Utilizing an online micro-lecture for asynchronous learning within the acting internship. Medical Science Educator, 30(1), 91-96. doi:10.1007/s40670-019-00887-y Haghighat, H., Shiri, M., Abdar, M., Harikandee, S., & Tayebi, Z. (2023). The effect of microlearning on trauma care knowledge and learning satisfaction in nursing students. BMC Medical Education, 23(1), 622. doi:10.1186/s12909-023-04609-2 Symczak, H., Olab, A., Mendrala, K., Plicner, D., Darocha, T., Podsiado, P., . . . Kosiski, S. (2021). Core Temperature MeasurementPrinciples of Correct Measurement, Problems, and Complications. PubMed Central doi:10.3390/ijerph182010606 Moola, S., & Lockwood, C. (2011). Effectiveness of strategies for the management and/or prevention of hypothermia within the adult perioperative environment. International Journal of Evidence Based Healthcare, 9(4), 337-345. doi:10.1111/j.1744-1609.2011.00227.x Munday, J., Delaforce, A., Heidke, P., Rademakers, S., Sturgess, D., Williams, J., & Douglas, C. (2023). Perioperative temperature monitoring for patient safety: A period prevalence study of five hospitals. International Journal of Nursing Studies, 143(104508). doi:10.1016/j.ijnurstu.2023.104508 Microlearning Effect on Patient Temperatures 21 Palmer, J., Soucier, M., & Deeds, J. (2019). An innovative warming strategy to increase patient satisfaction. NURSING, 49(7), 49-53. doi:10.1097/01.NURSE.0000559920.61696.84 Rauch, S., Miller, C., Brauer, A., Wallner, B., Bock, M., & Paal, P. (2021). Perioperative HypothermiaA Narrative Review. International Journal of Environmental Research, 18(16). doi:10.3390/ijerph18168749 Robles, H., Jimeno, M., Villalba, K., Mardini, I., Nuez, C., & Florian, W. (2023). Design of a microlearning framework and mobile application using design-based research. PeerJ Computer Science. doi:10.7717/peerj-cs.1223 Shail, M. (2019). Using Microlearning on Mobile Applications to Increase Knowledge Retention and Work Performance: A Review of Literature. Cureus, 11(8). doi:10.7759/cureus.5307 Statology. (2021). How to Determine Equal or Unequal Variance in t-tests. Retrieved from Statology: https://www.statology.org/determine-equal-or-unequal-variance/ Straus, S., Tetroe, J., & Graham, I. (2009). Defining knowledge translation. Canadian Medical Journal Association, 181(3-4), 165168. doi:10.1503/cmaj.081229 Zarshenas, L., Mehrabi, M., Karamdar, L., Keshavarzi, M., & Keshtkaran, Z. (2022). The effect of microlearning on learning and self-efficacy of nursing students: an interventional study. BMC Medical Education, 22(664). doi:10.1186/s12909-022-03726-8 Microlearning Effect on Patient Temperatures Appendix A: 22 SWOT Convenient Sample Strengths Active Benchmarked Metric Micro Learning Applied Management Approval Academic Motivation Weakness Time Period Zero Fiscal Budget Restrictive Access Perioperative 2nd Layer Data Genesis Opportunity Discovery Tool Optimized Thermoregulation Improved Patient Outcomes Participation Not Mandatory Threats Staff Autonomy Staff Task Volume Lack of Incentive Human Error Microlearning Effect on Patient Temperatures Appendix B: KTA Cycle 23 Microlearning Effect on Patient Temperatures Appendix C: 24 Qualtrics Pre/Post Knowledge Survey Questions with Informed Consent Informed Consent By clicking "Next,'' you consent to voluntarily participate in this quality improvement project. This activity includes a 10-item survey before and after a brief educational offering. Participation or non-participation will not impact your employment status. No identifiable information will be collected. Results will not be provided. The estimated time to complete this project is 15 minutes. Thank You for Your Time & Efforts Q1: Do you consider surgical thermoregulation a critical factor contributing to patient outcomes? Yes No I am not sure Q2: Perioperative hypothermia is generally considered to be any temperature less than ____. 98o F (36.7o C) 97o F (36.1o C) 96o F (35.6o C) 95o F (35.0o C) none of the above I am not sure Q3: ___ is the "sweet spot" body temperature for adults throughout the perioperative process. 95.9 F to 97.7 F (35.5 C to 36.5 C) 95.9 F to 99.5 F (35.5 C to 37.5 C) 97.7 F to 99.5 F (36.5 C to 37.5 C) 97.7 F to 101.3 F (36.5 C to 38.5 C) None of the above I am not sure Q4: Which of the following examples reflect active body surface warming interventions to optimize thermoregulation for surgical patients? select all that apply Track patient temperatures before, during, and after surgery. Provide warm cotton blankets before surgery in the preoperative area. Apply active body surface warming devices intraoperatively prior to induction. Limit patient skin exposure Warm irrigation fluids None of the above I am not sure Q5: Which of the following is most responsible for heat loss ? Head Peripheral Arms and Legs Skin Groin, Armpits and Neck None of the above I am not sure Microlearning Effect on Patient Temperatures Appendix C: - contd: Qualtrics Pre/Post Knowledge Survey Questions with Informed Consent Q6: Which of the following are possible consequences of unintentional hypothermia? select all that apply Infection Poor Wound Healing Increased Blood Loss Increased Pain Increased Length of Stay None of the above Q7: How does surgery affect patients' ability to regulate their temperature ? Surgical procedures do not hinder a patients natural ability to self-regulate temperature. During surgery, patients are able to sense temperature change and physiologically adjust. Medications used in surgery hinder a patient's natural ability to respond to external influences such as surgery, pain, blood loss, injury, exposure or cold. All of the above None of the above I am not sure Q8: According to Facility Perioperative Policy 660-76, patient temperature should be assessed__ Preoperatively, before the patient heads back to surgery Intraoperatively, during surgery Postoperatively, after surgery Throughout the perioperative process None of the above I am not sure Q9: According to Facility Perioperative Policy 660-76, The minimum patient temperature that should be maintained throughout the operative process is _____. 95.0o F 96.0o F 97.0o F 98.0o F 98.6o F None of the above I am not sure Q10: According to facility Perioperative Policy 660-76, for patients undergoing general anesthesia, forced-air warming should be _________ select all that apply used throughout the operative period. adjusted to achieve desired therapeutic goals. when the patient temperature is below 98o F. for procedures more than 30 minutes in length. for procedures involving an open cavity for procedures involving bilateral extremities. none of the above 25 Microlearning Effect on Patient Temperatures 26 Appendix D: Pre / Post Microlearning Data Collection Template: example data Surgery Type: General Maximum: 100 Minimum: 94.0 Max Change: Urology Preop Temp: 98.4 Average: 99.1 Mode: 97.2 Minimum Change: Neuro Intraop Temp: 98.1 # < 96.0o F: 4 % cases < 96.0o F: 12 Postop Temp: 98.9 Overall Maximum Overall Minimum Maximum Score: 30 Minimum Score: 10 Average Score: 27 Perioperative Staff Data Microlearning Effect on Patient Temperatures 27 Appendix E: Descriptive Statistics Pre-Microlearning Regression Analysis Column1 Column2 Column3 Mean Standard Error Median Mode Standard Deviation Sample Variance Skewness Minimum Maximum Sum Count Largest(1) Smallest(1) 98.093 0.145 98.000 98.100 0.767 0.589 0.678 96.900 99.800 2746.600 28.000 99.800 96.900 Mean Standard Error Median Mode Standard Deviation Sample Variance Skewness Minimum Maximum Sum Count Largest(1) Smallest(1) 97.989 0.182 98.000 97.000 0.964 0.930 0.657 95.900 100.900 2743.700 28.000 100.900 95.900 Mean Standard Error Median Mode Standard Deviation Sample Variance Skewness Minimum Maximum Sum Count Largest(1) Smallest(1) Confidence Level (95.0%) 0.298 Confidence Level (95.0%) 0.374 Confidence Level (95.0%) 98.1 0.11 98.1 97.7 0.62 0.39 0.28 97.0 99.7 2749. 28.0 99.7 97.0 0.24 Post Microlearning Regression Analysis Column1 Column2 Column3 Mean Standard Error Median Mode Standard Deviation Sample Variance Skewness Minimum Maximum Sum Count Largest(1) Smallest(1) 97.913 0.199 98.000 98.000 1.108 1.228 -0.650 94.700 100.000 3035.300 31.000 100.000 94.700 Mean Standard Error Median Mode Standard Deviation Sample Variance Skewness Minimum Maximum Sum Count Largest(1) Smallest(1) 97.419 0.212 97.300 96.400 1.182 1.396 0.637 95.400 100.000 3020.000 31.000 100.000 95.400 Mean Standard Error Median Mode Standard Deviation Sample Variance Skewness Minimum Maximum Sum Count Largest(1) Smallest(1) Confidence Level (95.0%) 0.407 Confidence Level (95.0%) 0.433 Confidence Level (95.0%) 97.8 0.14 97.7 98.3 0.77 0.60 0.77 96.8 100.0 3032. 31.0 100.0 96.8 0.28  ...

... LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 1 Lived experiences of formerly incarcerated mothers: Navigating societal stigmas and barriers impeding their pathways to pursue higher education _______________________________________________ A Capstone Project Presented to The Faculty of the Fred S. Klipsch Educators College Marian University ________________________________________ In Partial Fulfillment of the Requirements for the Degree Doctor of Education in Organizational Leadership ____________________________________ Lesley Neff, Ed.D. Summer 2023 LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS Copyrighted by Lesley Neff All Rights Reserved 2 LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 3 Abstract This qualitative research study used a phenomenological approach to explore the lived experiences of formerly incarcerated mothers in Indiana, as they navigate their return to the college classroom, given the stigma attached to justice involved individuals and motherhood. While significant research exists on incarcerated mothers, parenting behind bars, family reunification, and external, structural obstacles faced by formerly incarcerated people upon reentry and their paths to college, there appeared to be little research on the experiences of the post-incarcerated mother, her post-secondary educational journey from prison to college and internal barriers specific to mothers. This study investigated the external obstacles faced by this non-traditional population through their lived experiences and how these obstacles uniquely impacted their fears, insecurities, identities and self-image and the influence of the distinct hardships in pursuing the steps needed to return to college. This study also investigated how equipped institutions of higher education are to serve this population and help to clear their paths, whether by banning the box on admissions applications or providing the needed support and services to formerly incarcerated mothers, so they can increase their emotional capacity to pursue their educational goals. Data was collected and analyzed via questionnaires, observations at a live workshop, a group debrief on Webex and one-on-one interviews with workshop participants to understand the impact of the interventions designed for the population of participants and improve the lived experiences of mothers with incarceration experience while pursuing college. Keywords: higher education, post-secondary education, college, motherhood, formerly incarcerated, incarceration experience, stigmatization, self-stigmatization, structural stigma, social stigma, justice involved individual/people, Post Traumatic Prison Disorder, Possible Selves, Self-efficacy Theory, Intergroup Contact Theory and Double Deviant Theory LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS Dedication I dedicate this capstone to my mother, Kathleen Ann (Kinkel) Neff, who is the center of everything, whose love and support has never known bounds. She has walked this journey with me, and this accomplishment is as much hers as it is mine. I also dedicate this capstone to the women the mothers - with incarceration experience or justice involvement, whom Ive had the privilege to know, who have touched my life over the years. To Anastazia, this is dedicated to you - you are the inspiration behind the work and everything I do. 5 LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 6 Acknowledgement I acknowledge my dad, David Neff, who has loved unconditionally; and my partner, April Priest, who has sacrificed a great deal for my continued education. I acknowledge my circle of friends my chosen family who have been strong supporters of all I do, particularly Leslie, Jada, Tina, Max, Jill, Pam, Angela, Damien, Abe, Sam and Stacy. I acknowledge all the scholars in the pre-college program past and present - at the Indiana Womens Prison who have inspired my path and this capstone project. I acknowledge my colleagues and mentors at Marian University, Dr. LaTonya Turner, Dr. Lori Rumreich, Bill Harting, Melanie Martz, Helen Buckley, Dr. Bessie Rigakos, Dr. Gay Lynn Crossley, Dr. Jeff Kaufman, Sr. Monica Zore and Deb Lawrence, all of whom believed in me over the years, at varying capacities, even when I did not. Finally, I would like to acknowledge my committee chair, Jeffrey Hannah, J.D., my mentor I would not have made progress in my journey without his compassion and influence. And my committee members, Dr. Holly Gastineau-Grimes, who has become a trusted confidant, and Dr. Elizabeth Nelson, my friend and hero for how she fights with endless passion for people and progress. LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS TABLE OF CONTENTS Page ABSTRACT 3 DEDICATION 5 ACKNOWLEDGEMENTS 6 CHAPTERS 8 - 115 I. INTRODUCTION & STUDY DESCRIPTION 8 - 21 a. SIGNIFICANCE OF STUDY 11 - 14 b. PRE-DIAGNOSTIC WORK 15 - 21 II. LITERATURE REVIEW 22 - 60 III. METHODOLOGY 61 - 69 IV. INTERVENTION DEVELOPMENT 70 - 78 V. INTERVENTION EVALUATION & FINDINGS 79 - 113 VI. SUMMARY OF FINDINGS & DISCUSSION 114 - 120 VII. FUTURE RESEARCH & CONTINUING THE WORK 121 - 125 VIII. CAPSTONE SUMMARY 126 - 127 REFERENCES APPENDICES 128 - 133 7 LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 8 INTRODUCTION We hold mothers in high regard in this country, if they meet traditional expectations of society, yet we are incarcerating them at startling rates, then setting them up for failure upon release. Our society holds mothers to a higher standard formerly incarcerated mothers even higher, and our communities and institutions can often place a burden on them. Not only are they stigmatized because of their criminal histories, they are ostracized because they are bad mothers, as Mitchell & Davis point out in their study these mothers are viewed as outcastsand dismissed [by society] as throwaway moms (2019, p. 423). There is minimal research on formerly incarcerated mothers, especially if it concerns advancing themselves, their college education or careers. This population may be overlooked in our society. Despite my involvement in education programs at the Indiana Womens Prison and having mothers as students during and post-incarceration, I had no initial interest in the mothers specifically and no intention of focusing on them until I listened to their narratives; my mind and heart were opened to the stigma and labels that follow them not only because of their criminal histories but also because they do not fit our societys definition of motherhood - and experienced their stories through a unique lens. I was judged very harshly for that [for being an incarcerated mother]. I was judged as being a bad parent it does not matter any of the values I taught my kids and how well they are doing what matters is that I was locked up. Period. The black mark against me is permanent. (Angela, personal communication, 2021). If mothers do not abandon their own desires for the child, they are selfish and shunned. K.B. shared (personal communication, 2021): My son now living with me full time makes me whole again, but I also want more than just that. I am a mom. I love being a mom. But I am more than that. I love all the thingsfor me, I needed more than that, and I do not want that to besomehow that I LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 9 care less about my child; if anything, I feel like it is giving him more. He doesnt need to feel like the center of the universe all the timeyes, I put him first, but there are other things happening in the world, there are other people in the world it is not always all about himhe needs to feel unconditionally lovedbut see the importance of the needs of others and those around him... (K.B., personal communication, 2021) Her next goal is to continue education on her own, in her way (K.B., personal communication, 2021) and is preparing to apply to law school. This harsh judgment in the community extends to the courtroom. Many assume judges will go easier on moms, but the opposite is more accurate - women are not supposed to commit crimes, much less mothers, how could a mom commit a crime and abandon her child? (K.B., personal communication, 2021). Society says it is more acceptable for men to commit crime, so women take a harder hit, and so when they come out, they also face a different kind of stigma, a different kind of expectation when it comes to parenting and are expected to put all the pieces back together to put themselves back together when we werent whole to begin with (K.B., personal communication, 2021). A.H. agreed there is still a traditional, conventional way of thinking in her community when it comes to gender roles its okay if the dad is locked up, but the mom?! Its likewhat?! she stated in a long, drawn-out tone (A.H., personal communication, 2021). It is inconceivable to so many people. The barrier and burden of being doubly ostracized for being a mom with a criminal history and the shame and guilt that may hinder these mothers from pursuing self-betterment through education should be in the forefront of institutions of higher education. Formerly incarcerated individuals face external obstacles, which hinder formerly incarcerated mothers quite differently, such as daycare, state supervision, student loan defaults, and job obtainment. These women also face unique internal barriers, upon re-entry, along their pathway to college, such as the effects of Post Traumatic Prison Disorder (PTPD). The external obstacles require LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 10 progress within our systems, while the internal barriers require progress within the mothers themselves and how they respond to stereotypes and stigma that is exacerbated by lack of knowledge and support facing countless challenges. Through pre-diagnostic work and research, these internal barriers emerged to be particularly intriguing how does fear of judgment, anxiety and low self-esteem prevent formerly incarcerated and justice involved mothers from a post-secondary education? How do external obstacles impact internal barriers, and how would the lessening of external obstacles lighten internal barriers? Which services and programs can be put in place to help these mothers find ways to make progress within themselves and build their own capacity to excel through the stigma? Why is post-secondary education so important, and why should our institutions and communities care? As discouraging as the external obstacles that impede the path to higher education may be, such as an admissions process that requires revealing criminal history and an inability to navigate financial aid or establish safe housing, the stigma surrounding formerly incarcerated mothers is real and incapacitating as is their unique fears about returning to the classroom. Who is a good mom in the eyes of the community, and who is a bad mom? If labeled a bad mom, as formerly incarcerated women automatically are, being accepted back into her community and improving her own life and the lives of her children is, in large part, dependent on her earning a college degree, which is difficult to achieve. The importance of a clear path to college runs deep for these mothers. It is only through education programs and institutions of higher education that these women can communicate with many support systems which originated inside the prison. For educational purposes only is the only exception by which they can communicate with a former professor or educational director LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 11 or leader during their incarceration if they are applying to college after release. Without these networks in place, the mothers may be more challenged; they are seen as risks instead of gifts (Halkovic & Green, 2015). These women would not have survived without the connections to the education people college is so vitally important (A.S., personal communication, 2022). Significance to Community: Practical and Scholarly This countrys prison population is the largest in the world, and over 600,000 people reenter from state and federal prisons annually (U.S. Department of Education, 2016; Kirp, 2021). The National Conference of State Legislators (Boggs, 2019) and The Prison Policy Initiative (Sawyer & Wagner, 2022) report that approximately 2.3 million people are incarcerated across the United States, and over 95% will be released back to their communities (Sawyer & Wagner, 2022; Bell, 2020; Kirp, 2021). Most adults who are currently incarcerated will be released back into society, and only 4% of formerly incarcerated people have a college degree (Bumgardner et al, 2019; Couloute, 2018), the lowest it has been since WWII before segregation was outlawed in public schools and before the GI Bill (Couloute, 2018). Less than 10% of formerly incarcerated individuals, who earned their GED while in prison, continue to college (Berkeley Underground Scholars, Our work, 2020). These people will be members of our community. They will be our neighbors, and their children will go to school with your children. There is little research on formerly incarcerated and justice involved mothers and how they adapt to college upon re-entry in a society in which mothers are leading the way to incarceration at alarmingly growing rates. Over the last 30 years, the number of women who are incarcerated in this country has grown 750% which is twice the rate of men (Equal Justice, 2020). In 2016, over 1.2 million women were incarcerated or on probation or parole; when released, they are often not prepared for re-entry, as so many services have been geared toward men (Substance Abuse and Mental Health Services Administration - SAMHSA, 2020). Women LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 12 also must face resurfacing challenges from pre-incarceration, and difficulty in school is listed as one (SAMHSA, 2020). Sixty percent of women who are incarcerated in state prisons have children under the age of 18 (Equal Justice, 2020). Many of these women are single mothers solely responsible for their children (Equal Justice, 2020). The Equal Justice Initiative articles focus is the toll on the children, which also seems to be the focus of our communities according to many sources and the voices of incarcerated and formerly incarcerated women, but what about the mothers being released into our community at growing rates. Education, employment and recidivism are all linked; according to the National Conference of State Legislators, prisoners who attend college have approximately a 10% higher chance of employment and better earnings (Bumgardner et al., 2019; Boggs, 2019) and a 21% return rate, meaning re-incarceration (Bumgardner et al., 2019). When recidivism is minimized by education programs during and post incarceration it can be up to an estimated $365 million dollar savings to taxpayers (Bumgardner et al., 2019; Boggs, 2019). According to Kirp, Building the prison-to-college pipeline is also a boon to the public. Taxpayers save a boatload a year in prison costs more than a year at Harvard (Kirp, 2021, para. 6). Beyond cost savings, formerly incarcerated students bring gifts and benefits to universities and their surrounding communities (Halkovic & Green, 2015). The presence of formerly incarcerated students can bridge relationships between academia and underserved communities. According to Bumgardner, Ending discrimination against formerly incarcerated people can also strengthen the university by increasing campus presence of people from underrepresented groups and admitting highly qualified and motivated students and employees who were previously barred (Bumgardner et al., 2019, p. 66). Formerly incarcerated students LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 13 can help academic institutions reach audiences and populations with whom it is often difficult for institutions of higher education to build trusting relationships (Halkovic & Green, 2015). Halkovic & Green (2015) send the message that by embracing the gifts of formerly incarcerated students, institutions of higher education put themselves in a unique position to help them make the transition from prison to community. The evidence presented poses that students with backgrounds that include incarceration enhance the university environment, not pose a security threat to it. These students can help to reduce stigma on campus and teach others to embrace students who are different and find empathy in place of prejudice. They have a true desire to give back more to the institution and community, be more engaged in the community and understand how systems work through their lived experiences. An example is best understood through the words of a formerly incarcerated social worker quoted in an interview in Halkovics study (2015, p. 772): A lot of people who are formerly incarcerated go into the human service fields; they have a deep sense of this is not enough. So I am working as a case manager and helping people but that is not enough. I am a mentor for College Initiative [a CBO that supports students getting into and through college post prison] but that is not enough. I volunteer at that spot on the weekends but that is not enough. I am going for my CASAC but that is not enough. Because they feel that I owe this to myself, I owe it to my family, I have an understanding of what my role and position is in society, in community and local level, at my agency, in my family. I know what my role is as a man, a husband, a father, and as a son. They have a deeper understanding of thatmen and women who are formerly incarcerated are more than likely doing more than just being a student at that campus. (2015, p. 772) Significance to Marian University Marian University has already recognized this student population and the importance of education; through a partnered program, women at the Indiana Womens Prison are earning Marian degrees while incarcerated (Cantrell, 2019). The organizations efforts in serving an underserved population aligns with the universitys mission and Franciscan values, particularly LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 14 the Dignity of the Individual (2022). Marian University is a Catholic Franciscan institution who welcomes all to join and strives to serve the world by providing an education that transforms hearts and minds of students through the integration of knowledge and faith (2022). That is the central focus of this study how to provide the support and services to a marginalized population of formerly incarcerated mothers, so that they may find the power within themselves to seek college self-efficacy. The interventions in this study are rooted in the adaptive leadership framework and geared toward a workshop for formerly incarcerated mothers to welcome them to post-secondary education. However, an opportunity for future research may develop in the proposed intervention being adapted and expanded upon to appeal to other non-traditional populations at Marian University, such as adult students - in online, asynchronous programs - returning to college after many years, veteran students, and the students in our two-year colleges. This makes this study and intervention significant to the entire community. Formerly incarcerated mothers is only one non-traditional population returning to college who face significant stereotypes and barriers on their pathways to college; if we can find a way to serve this population and prepare them to face the challenges and stigmas, we should be able to better prepare many other non-traditional populations to return to the classroom and make progress. If successful, the Marian University Pre-College Workshop could become a series each dedicated to a non-traditional student population making their way back to the classroom. LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 15 PRE-DIAGNOSTIC WORK Minimal literature addresses the stigma and the challenges surrounding formerly incarcerated mothers pursuit of college, so direct communication with the women is imperative. From communicating with formerly incarcerated mothers over the last six years, volunteering and teaching at the Indiana Womens Prison, and interviewing justice involved and formerly incarcerated mothers for prior coursework, I was able to help fill in the gaps in the literature and more intimately address the unique, real-world obstacles formerly incarcerated mothers face because of not fitting the stereotypical image of a mother or of a college student. There is a stigma surrounding mothers with criminal records. Societal stereotypes follow them to workplaces, soccer fields and classrooms, and the fear of re-entering society at any capacity may feel overwhelming for some women, not to mention the return to a college campus or classroom in which they have no understanding of how to navigate, from admissions to financial literacy to acceptance by professors and peers. The mothers revealed these challenges in personal narratives over the years and in more recent interviews last year for a qualitative research course and can be broken down into three unified themes: The Bad Mom Box One theme is well articulated by formerly incarcerated mom, K. B. who acknowledged that even mothers who do not have criminal histories face severe judgment in our society the criminal history part brings an additional dynamic (personal communication, 2021). Based on decades of experience as a social worker and working with formerly incarcerated mothers, W. M. agreed and said mothers are judged more harshly than fathers, and society is quick to judge from housekeeping to breastfeedingwomen just get hit from every direction (W.M. personal communication, 2021). One of the incarcerated women at Indiana Womens Prison has presented LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 16 this argument over the last few years about sentencing, stating that men are sentenced as men, and women are sentenced as mothers (L. H., personal communication, 2019). The claim is that Court systems hold mothers to a higher standard, hence they receive harsher sentences than men (or fathers); society really struggles to forgive mothers and welcome them back into their communities, so they face significantly more discrimination, because they have stepped outside the traditional gender expectation of law-abiding behavior (L.H., personal communication, 2019; K.B., personal communication, 2021). It does not take much to be labeled a bad mom, as Mitchell and Davis explore in their study (2019). Formerly incarcerated mothers are automatically placed into the bad mom box. When mothers do pursue education or a career, every dream you have, every hope, every chance of achieving something for yourself has to be shoved to the backburner, or there is guilt (K.B., personal communication, 2021). She said that society puts that guilt on mothers, and she does not think fathers have that same pressure or expectation and that we hold moms to an impossible standard (K.B., personal communication, 2021). She explained that coming out of incarceration, there is always that pressureI cannot dare miss a soccer gameeven if I justify it in my own head, then I feel the guilt and the shame when I am around other people (K.B., personal communication, 2021). Why is she just now showing up to soccer games? Where has she been? She is automatically placed in the bad mom box. If a mom does not have custody of a child/children, people automatically think negatively about the mother or that the mother must not care (K.B., personal communication, 2021). A. H. felt that same pressure; she was thrown back into being a mom (personal communication, 2021). Her daughter was 2 years old when A.H. began serving her sentence at the Indiana Womens Prison. During re-entry, I was building my entire life up from nothing, from LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 17 toothbrush to spatula in the kitchen (A.H. personal communication, 2021), trying to finish school and maintain employment to pay for everything. There is still this mentality that kids are supposed to be with mom, and my situation is way outside of that box (A.H., personal communication, 2021) because her daughter still lives with her father full-time, which A.H. fully supports. Another formerly incarcerated mom sums it up well: social norms are not so normal (Angela, personal communication, 2021). Angela feels like there is a specific role that is still expected of mothers; Indianapolis seems behind the times on women and motherhood [and sees mothers] as still being at home, taking care of the home and kids (personal communication, 2021). Importance of Post-secondary Education The second theme is the importance of a college degree for justice involved people, especially mothers, and the message it sends to their children. Despite how crucial college is for this population, mothers are villainized for wanting more when they go back to school (K.B., personal communication, 2021), and in a sarcastic, gasping tone mothers coming out of incarceration think they have a right to an education and career how dare they (K.B., personal communication, 2021), followed by laughter. A. H. believes that mothers going to college and exploring their own paths sends a powerful message to their children and makes them better prepared for the world (personal communication, 2021). She believes the completion of her college degree sent a message to her daughter: I did it. You need to do it. School is important she got to witness that (A.H., personal communication, 2021). K.B. wanted to set an example for her son that anything is possible, and no matter what, you can do anything, and her education was one way of showing him (personal communication, LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 18 2021). K.B. was the first one in her family to go to college she always wanted her education our pathways, our desires, our goals are taken as a rejection of theirs (personal communication, 2021) she says about her family, but this applies to our societys views on motherhood. Formerly incarcerated mothers in pursuit of personal achievement whether education or otherwise is seen as a rejection to traditional values and definitions of motherhood. K.B. and Angela both have plans to continue their education past the bachelor level; Angela shared how her pursuit of higher education post incarceration impacted her daughters in a powerful way (personal communications, 2021). Her kids were not passionate about school originally, but as I was hitting all these milestones [such as graduating summa cum laude], her kids became competitive with each other over who got the best grades (Angela, personal communication, 2021). It was a true turning point (Angela, personal communication, 2021). It gave her daughters the drive to make sure their grades were good and motivated them to go on to college your kids mimic you and if they see education is important to you, it will be important to them [pause]on some level (Angela, personal communication, 2021). Mothers who achieve remarkable things, especially when the odds are against them, inspire their children to do the same (Angela, personal communication, 2021). Angela is starting graduate school in Fall 2023. Stigmatization on Campus & Self Efficacy The third theme focuses on the stigmatization of the industry of higher education and whether the formerly incarcerated mothers belief in their capacity can overcome barriers rooted in prejudice and stereotypes. Mothers lose their voice because they have a pasteverything has to be perfect, and the slightest mistake or stray from the norm, everyone is quick to remind you, exclude you, talk about you, and you have to prove yourself at every turn (K.B. personal LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 19 communication, 2021). A. H. said that you can see the disgust on some peoples faces (personal communication, 2021), and because of this, you are not allowed to slip up to the point of being afraid to even try. K. B. is familiar with the look; just arriving late to a soccer game other moms are looking at me sideways (personal communication, 2021). Angela said (personal communication, 2021), I was a machine. Everything about me had to be perfect. These fears of judgment and not being accepted into their environments are examples of the paralysis formerly incarcerated mothers feel when seeking education. How will the cycle stop if mothers are not supported upon release, and that includes attacking the stigma attached to formerly incarcerated moms and encouraging them to continue their education (K.B., personal communication, 2021)? The stigma is real, and attacking it is not so easy. W.M. taught a college course at an institution in Indiana called Orange is the New Black (personal communication, 2021). The students stereotyped all incarcerated people as bad, regardless of the crime, but W.M. was able to draw out empathy, eventually, for incarcerated women and mothers (personal communication, 2021). The more the students became educated on why women and mothers were being incarcerated, the more they softened, which supports the Binnall et al study on college students views changing the more they become involved in the lives of their formerly incarcerated peers (Binnall, Scott-Hayward, Petersen, & Gonzales, 2021). Angelas narrative about her return to the classroom is evidence to how far justice involved students may go to keep their criminal histories hidden, even after a peer relationship is developed. She was only able to thrive in her mothers Florida community because no one knew about her past, and she worked hard to keep it that way (Angela, personal communication, 2021). Angela pretended my past never existedit made me feel deceitful and eliminated my ability to LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 20 fully connect with others, but it kept her from being judged (personal communication, 2021). Her need to belong was real. She lived in secrecy. She was worried about going to the probation office and being seen by a classmate. Angela assumed a false persona in Florida because her fear of judgment and not being accepted was that strong. The risk was too great - she could not risk her classmates and professors finding out about her criminal history. (Angela, personal communication, 2021) Angela said of her secrecy, I protected and maintained itit was like a job in and of itself (personal communication, 2021). She longed for belonging. Angela shared a memory of a Florida classmate, who received a speeding ticket. Angelas former classmate was upset about going to court over a speeding ticket and felt embarrassed - she looked at Angela, and said, oh but you wouldnt know anything about that (personal communication, 2021) as in going to court and feeling the shame of breaking the law. This exchange impacted Angela so greatly that her memory all these years later is quite vivid down to the classmates clothing and body language the girl was wearing a white sleeveless polo golf shirt, khaki pants, flip flops and was sitting at her desk with her long brown hair pulled back with a headband and had her hand on her head, leaning her arm on the desk, stressed out over this speeding ticket (personal communication, 2021). I was no better than her but Angela could never let her know that (personal communication, 2021). On the outside, she had to look perfect had to look the part. Angela had succeeded in maintaining a perfect persona. (Angela, personal communication, 2021) The double stigma attached to justice involved mothers and the barriers unearthed by a disparaging society became apparent in speaking with the mothers over the years. Their genuine expression of fear and anxiety that comes with being placed in the Bad Mom Box were LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 21 powerful moments that reinforce some of the arguments made in this studys literature and carry them to a new level. The stigma is so intense that women go to desperate lengths to be accepted. LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 22 REVIEW OF THE LITERATURE Relevant literature emerged from conversations with local scholars who work with the justice involved and formerly incarcerated populations, formerly incarcerated scholars, online searches and exploring databases of scholarly journals and qualitative and mixed methods studies, as well as websites of other organizations and institutions who have dedicated themselves to advancing opportunities for formerly incarcerated people at institutions of higher of education. There is considerable research on the external obstacles people face upon re-entry alone, not to mention returning to the college classroom. Countless journals, articles and studies focus on transportation, housing, childcare, parenting education, family reunification, mental health counseling, and banning the box, and while these obstacles are important to understand and address because they contribute to emotional capacity, the core of this study turns to internal barriers of stigmatization, stereotypes and self-efficacy and the college specific external obstacles that impact them. There is minimal literature on the stigma attached distinctly to formerly incarcerated mothers, and this is an area on which a reasonable amount of progress may be made. There is minimal literature on making college a realistic possibility for mothers specifically and what exactly makes this population so unique. Sources, such as the Substance Abuse and Mental Health Services Administrations (SAMHSA) After incarceration: A Guide to helping women re-enter the community, presents interesting information and statistics, but not much is said about women returning to college (2020). The focus on education is about mental health education and being a better parent not the mothers bettering themselves through college. The education section of the guide to help women consists of a three-sentence paragraph about women taking parenting classes. SMHSA focuses on the effect of maternal incarceration on the children (2020, p. 20) more than the mothers themselves, the trauma of LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 23 incarceration and how that impacts self-efficacy and self-esteem to pursue college. Sherman points out many obstacles unique to women and mothers issues related to child custody, repairing broken relationships, assuming the parenting role, and providing family stability are often urgent, yet stressful experiences (2017, pp. 15-16). While there is a focus on motherhood and what is distinct about a mother re-entering the community, again the focus is on parenting and child relationships, not the betterment of the mothers through their own educational pursuits. With some of the sources, it is what they do not address more than what is addressed. Importance of Post-secondary Education Higher education offers a transformative opportunity to improve life circumstances for millions of people with a history of involvement with the criminal justice system (Ott & McTier, 2020, p. 297). Formerly incarcerated people often turn to education to help navigate the pitfalls of re-entry (Binnall, Scott-Hayward, Petersen & Gonzales, 2021), and securing a college education for the formerly incarcerated can break intergenerational cycles of poverty and crime (Kirp, 2021, para. 6). In one study, 357 women were interviewed from 11 states upon prerelease, and 95% said their biggest need was education, followed closely by employment and job readiness (Bell, 2020; Garcia & Ritter, 2012). Results from a qualitative study in 2009 suggested a positive relationship was found between a womans post-secondary degree and her ability to manage stress and emotional strain from incarceration and re-entry (Parker, 2009). Enrolling in higher education post-release increases job opportunities and decreases the likelihood of reoffending. Of the 600,000 people incarcerated annually, 95% will return to their communities, but of those, three-fourths will return to prison; it is a revolving door (Kirp, 2021). The best way to break this pattern is to give former inmates the chance to enroll in college as well as the financial and psychological support essential for success (Kirp, 2021, para. LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 24 5). Statistics show that only one in six with an associate level degree and one in 20 with a bachelor level degree ever return to prison (2021). College also has a positive impact on formerly incarcerated womens emotional capacity (Bumgardner, Byers, Campbell, Crawford, Jones, Fleming, Hauk, Hochstetler, Kelly, Kovats, Lipscomb, McCown, Oliver, Record, Pender, Schmid, Walls & Whitted, 2019). A formerly incarcerated scholar and co-author of Spotlight on Indiana: Barriers to higher education for incarcerated and formerly incarcerated students shared (Bumgardner et al, 2019, p. 77): Education has changed my life. The work that I do. Not only did it give me confidence in myself and boost my esteem, which is something that lacks severely, especially in women who are incarcerated due to childhood trauma. Yeah, it gave me the tools to build myself up to believe in myselfI found meaning in my work, especially as a historianspeaking for women who have been subjugated or incarcerated in the past and don't have that voiceIt's very powerful. And then also some of my work includes trying to break down some of the struggles and the barriers that you experience after you're released. And so that's very meaningful and just gives me a purpose and it keeps me on track, and it keeps me away from negative influences. It keeps me away from negative places and it puts me in a circle with all positive people who are goal oriented. And that made a huge, I mean, I cannot stress this enough. It made all the difference and it's no wonder that people go right back to prison. I have a huge support system now in the circle of people that I'm in now that I would not have had otherwise. And a lot of people don't have access to it is absolutely no wonder they go right back. (Bumgardner et al, 2019, p. 77) There are benefits to higher education for the formerly incarcerated, from lessening the likelihood of recidivism to better financial opportunity (Binnall et al., 2021; Halkovic & Green, 2015). Education is key to these mothers finding employment (Couloute, 2018) to support their children. Couloute states that formerly incarcerated people are often relegated to the lowest rungs of the educational ladder (2018, para 1). Formerly incarcerated mothers are one rung below that. Without finding acceptance in their communities and dedicated space in institutions of higher education, these formerly incarcerated mothers have little chance of transforming societal stereotypes or themselves. LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 25 External Obstacles College Specific It is essential to understand the external obstacles faced by formerly incarcerated people and how these obstacles uniquely impact formerly incarcerated and justice involved mothers fears, insecurities and self-image which create distinct hurdles in pursuing the many steps needed to return to college. The study, Spotlight on Indiana: Barriers to higher education for incarcerated and formerly incarcerated students is authored by incarcerated and formerly incarcerated women in Indiana and addresses many of the external obstacles that incarcerated and post-incarcerated women face in Indiana when it comes to obtaining access to education, whether inside the facilities or upon release in their communities (Bumgardner et al., 2019). For the sake of this study, the focus will only be on the formerly incarcerated and re-entry obstacles related to college. Their study addresses lack of funding and affordability, accessibility, admissions set-backs, lack of educational programs and resources, the burden of parole and probation, and defaulted student loans. These obstacles are compounded by internal barriers, such as Post Traumatic Prison Disorder and the stigma of incarceration. College Admissions Many colleges and universities ask applicants to reveal disciplinary history and criminal history and cite campus safety concerns as their reasoning (U.S. Department of Education, 2016), despite limited data and research to prove a connection between campus safety and criminal justice history (U.S. Department of Education, 2016; Ott & McTier, 2021). In fact, a considerable majority of campus crime is committed by those with no prior criminal record; we tend to not think about how race, gender, class or privilege may keep someone who broke the law from being arrested, charged and convicted (Halkovic & Green, 2015). LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 26 Asking the question on college applications started in 2006, making it part of the Common Application which asks for students criminal histories have they ever been adjudicated guilty or convicted of a misdemeanor, felony or other crime (U.S. Department of Education, 2016, p. 10). Nearly 700 colleges use this Common Application, and while some decide to make answering that question optional (U.S. Department of Education, 2016), about two thirds of institutions request criminal history information, and a third of those deny admission based on the crime (Ott & McTier, 2020). Even though over 800 colleges and universities recently removed a question about criminal history from the Common Application in August of 2018, they still have the option to request information about involvement in the criminal justice system (Ott & McTier, 2020). Schools who use their own application may choose to ask the criminal history question in a variety of ways. Questions about criminal history alienate applicants and limit schools applicant pools (U.S. Department of Education, 2016). Many applicants never complete the application process, as when they come to the criminal history question, they quit over the anxiety, shame and embarrassment of revealing a crime or conviction (U.S. Department of Education, 2016). It is estimated that institutions lose two-thirds of formerly incarcerated applicants just by asking the question (Binnall et al., 2021). The report also claims that very few students who attend college report prior felony convictions on their admissions applications which is why there is limited data connecting this to crime on campus (U.S. Department of Education, 2016), but the report does not address why. It could be that applicants do not reveal this, or it could be that they just are not applying due to the overwhelming fear the question evokes. Couloute addresses these same concerns that if applicants must reveal criminal history, they do not even complete the application process to avoid facing discrimination due to their LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 27 pasts (Couloute, 2018). Beyond the question on admissions applications, there is also the issue of occupational licensing barriers upon graduation (U.S. Department of Education, 2016; Couloute, 2018). The admissions process, while a structural obstacle, often exacerbates PTPD, Post Traumatic Prison Disorder, an internal barrier faced by many formerly incarcerated people, especially women and mothers as their pathways to and from prison look quite different (Bumgardner et al., 2019, p. 81). One of the authors describes how devastating her admissions process was at a university in Indiana (2019). She spent many years trying to lay her past to rest and better herself through education programs while incarcerated but being forced to divulge her criminal history in a separate application process was humiliating. She had to relive a past she was trying to forget, a past as a drug addict, but that is not who she is today. She shares her emotions in Spotlight on Indiana: Barriers to higher education for incarcerated and formerly incarcerated students (Bumgardner et al., 2019, p. 81): I found it humiliating. I found it humiliating to expose my deepest, darkest secrets, things that I would love to bury in my past, to a bunch of strangers who I knew only wanted that information so that they could judge me based on what I had doneand what I had done in no way, shape or form reflected me as a person. It reflected me as a drug addict. I'm not the same person sober as I am on drugs, nothing even close to the same person. And so, I hated to introduce them to that person because that's not who's coming to this college whatsoever. (Bumgardner et al., 2019, p. 81) It took months for her to be admitted. Admissions told her it was for the safety of the campus (Bumgardner et al., 2019, p. 81). Formerly incarcerated applicants face many hurdles in the college admissions process. Many applicants are denied admission due to felony records (Bumgardner et al., 2019). Not only do most colleges and universities in the State of Indiana require applicants to check the box if they have a criminal record, but they are required to write a detailed narrative of the events that LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 28 led to the charges, even including information about victims and losses (Bumgardner et al., 2019). Aside from a written narrative about the details of their crime and conviction, some institutions require applicants to complete additional interviews, produce multiple references and have had completed any state supervision requirements, such as probation or parole, before being considered for admission (Binnall et al., 2021). Checking the box and revealing details of criminal history weaponize stigma upon the formerly incarcerated (Bumgardner et al, 2019, p. 65). Financial Limitations & Technology Spotlight on Indiana: Barriers to higher education for incarcerated and formerly incarcerated students (Bumgardner et al., 2019) addresses financial barriers faced by the women post-incarceration, such as daycare, housing and transportation, even food, clothing, hygiene and cell phones or other technology access needed for basic connections and survival. Financial limitations impact mothers re-entry (Sherman, 2017). While incarcerated, the women have little to no access to technology, and if there is any technology at all, it does not allow them to connect to the outside world. One of the women describes it like this (Bumgardner et al., 2019, p. 58): Nobody, and I mean nobody, prepared me in any way for the technology that I would have to deal with coming out into the outside world. And I would have to say for me, personally, that's been one of the biggest barriers to overcome. I mean, how do I work the cell phone and the computer and all of these things that did not even exist before I went in? I joke about this all the time, but I swear to God, I'm so serious. It's like I'd been trapped on Gilligan's Island for eighteen and a half years, talking through a coconut, and now, Here you go. Here's your cell phone and your smart phone and your Mac computer and all these great things and carry on. (Bumgardner et al., 2019, p. 58) It is impossible to survive college without at least a basic level knowledge of technology. One of the authors and formerly incarcerated mothers said, if you don't have that knowledge, you're handicapping somebody almost to the point of incapacitation They cannot function not knowing how these things work and how the world works now. So, this is something that we LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 29 need to keep in mind above and beyond just barriers to higher education, just education and knowledge in general. (Bumgardner et al., 2019, p. 80). Some of the women formerly incarcerated in Indiana who have enrolled in online programs went through a tremendous adjustment. While online classes may be more convenient, the learning curve is remarkable, from learning how to download Word and attaching a document to an e-mail to navigating an online platform that houses all the course content. One formerly incarcerated mother who is currently enrolled in online programs shared her experiences getting adjusted (L.H., personal communication, 2022): I felt like I was starting over with every bit of computer knowledge. Everything I learned while incarcerated no longer applied because I was online. Didnt know how to use Wi-Fi and still dont understand the purpose of a hotspot. When I transitioned to online courses, I felt like Fred Flintstone in a George Jetson eraI got major grade deductions for submitting speeches without sound because I didnt think to check to see if it was on. I am still learning how to use functions 11 months later that could make my life much easier. I can only navigate through my classes the initial way I learned which is probably the most difficult way, and if I accidentally do something different or easier, I dont remember how I did itI am still learning how to use my phone. The phones of the present are mini computers, and I get lost in them, too. (L.H., personal communication, 2022) All this technology costs money. Financial strain is one of the most significant challenges to re-entry in Shermans qualitative studys interviews with formerly incarcerated mothers (2017). Meeting basic needs such as housing and clothing costs money, and they often must pay legal fees. Due to their criminal histories, finding employment is difficult. One of the women described her struggle with the truth; she wanted to be truthful with potential employers, but when she was, they would no longer consider her for employment. She contemplated lying on the application, but she considered the consequences of that as well. Several of the women interviewed landed jobs they loved; then, they lost the jobs when their employer found out the LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 30 details of their crimes through background checks, even though they revealed their history in the interview and application processes. Parole & Probation Coming out of prison, recently released students are often on parole or probation which demands a great deal of time, travel and money the fees can be a heavy lift without support, a degree or employment, and state supervision can go on for months, even years (Bumgardner et al., 2019). Unfortunately, many of the parole and probation officers are not supportive of education and often put additional barriers in place which make it difficult or even impossible to return to college post-incarceration (Bumgardner et al., 2019). Some universities may offer housing and job opportunities to formerly incarcerated students, which may require relocation out of state, and the parole or probation officer may block the relocation (Bumgardner et al., 2019). They can spend half the day waiting for an officer to be available for required meetings, go to random drug tests and required therapy. This interferes with employment and any hope to continue college. One of the women shared her lived experience (Bumgardner et al., 2019, pp. 63-64): I was released from prison with 3 felonies, 2 publications, 1 statewide writing award, a 3.79 GPA, 54 total college credit hours earned, and $32,235.52 in defaulted student loan debt ($11,158.57 of which is solely interest). I was to immediately start serving a yearand-a-half on house arrest at $70.00 a week plus $25.00 per random drug test. I had no possessions (not even clothes), no license, no car, no job, and no money. But clearly, I had plenty of debt!... I bring up the license barrier because not only was it in fact a barrier of sorts that could ultimately keep me from going to school, or getting a job that would allow me to pay for school, but also because the fines and bureaucratic red tape associated with reinstating a license is . . . a prime example of systematic oppression of the poorer citizens of this country. In order to get my license reinstated after being suspended for non-proof of insurance 10 years prior, I had to first pay the fine of $526. Next I had to have proof of insurance just to have a license, which cost me another $50 per month! If my insurance were ever to lapse, my license would be automatically suspended again. After this step I had to pay $35.00 to take a BMV required online drivers safety course. Finally, after a month of fulfilling requirements, I was eligible to go to the BMV and pay $17.50 to take my written and driving exam I could only enroll in LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 31 two classes this semester, which is costing me $2,268.00 out of pocket. Just to give you an idea of my current financial situation I am having to pay monthly $435.00 for tuition, $280.00 for house arrest, $25-$50 for drug tests, $50.00 for car insurance even though I dont own a car, $5.00 for student loan repayments, and $50.00 just for basic needs, not to mention schoolbooks and clothes. That equals $845.00, but I only make $800 a month at my job! How is one who is poor enough to need federal student aid in the first place supposed to pay college tuition without financial aid or loan assistance? (Bumgardner et al., 2019, pp. 63-64) There are so many perceived external barriers that plans to go to college are often abandoned no matter how important education is to the women. Being under state supervision is even more challenging for mothers, increasing demands and even involving child welfare services (Mitchell & Davis, 2019). Upholding the obligations they had to their children, as well as the criminal justice system, often presented a conflict for the women (Sherman, 2017, p. 71). Mothers are often torn between caring for children and meeting the requirements of the state, so they do not reoffend. Many of the women interviewed in Shermans study realized that if they put themselves first, their children would be better off in the long run. Probation fees and parole barriers have significant impact on re-entry success and not only keep them from college, but it also often keeps them from seeing their children, especially if they must cross state lines. Mothers often must negotiate the continuous conflict between work demands, childcare and state supervision requirements (Ferraro & Moe, 2003). Student Loan Defaults & Financial Aid While incarcerated, many default on student loans due to non-payment. Spotlight on Indiana: Barriers to higher education for incarcerated and formerly incarcerated students (Bumgardner et al., 2019) explores the lived experiences of formerly incarcerated women who were not able to return to college upon release due to defaulting on loans while incarcerated, often because they were arrested mid-semester. The report claims this is often the most cited reason for not continuing education upon release - defaulted loans. However, there is an LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 32 inexpensive procedure that can rehabilitate the loans, (Bumgardner et al., 2019) but the women are often unaware of this, and the paperwork is daunting. If someone on the outside is not doing the research and the legwork, it is next to impossible to accomplish from inside facilities. Consolidation of loans is an option which can make the women eligible for repayment plans, Pell grants and forgiveness programs (Bumgardner, et al, 2019). Most are unaware of this, and even if there is awareness, this requires entering a new contract, which incarcerated people are not allowed to do. Many of the women try to work with agencies while inside to set up a plan on defaulted loans but are given the run-around. Without the outside support of family or friends, the women were only able to use the mail system and just sent in circles (Bumgardner et al., 2019, p. 17). Some were able to suspend collection activity, but loan debt was considered due in full. The barrier of defaults is even more significant upon release; they are unable to fund their education on the outside and often have their wages garnished and face damaged credit ratings (Bumgardner et al., 2019). One of the women explained that failing to get out of default while in prison made enrolling when she got out seem impossible (2019, p. 20). Years after her release, she is unable to afford the payment plan for her loans and said, my dream to get my college education was continuously being pushed further and further away (2019, p. 20). She goes on to explain how crucial a college education is for formerly incarcerated people, as they face many challenges to establish a career and advance their lives. (Bumgardner et al., 2019) The Spotlight on Indiana: Barriers to higher education for incarcerated and formerly incarcerated students recommends several solutions to the default loan problem, one of which involves the creation of a pilot program to get everyone in prison who has defaulted on loans out of default (Bumgardner et al., 2019). If the process was streamlined and incarcerated and LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 33 formerly incarcerated scholars were more knowledgeable on the process and options, college could become a more realistic possibility. There are also federal, state and institutional policies that prevent access to aid depending on the crime (Ott & McTier, 2020). Even those who manage to get admitted and produce the funding, they are limited on which campus activities they can participate, in which majors they can enroll and on campus employment opportunities (Ott & McTier, 2020; Halkovic & Greene, 2015). Connecting External Obstacles to Internal Barriers & Stigmatization Ott & McTier refer to these obstacles regarding admission and financial aid as examples of structural stigmatization while how the formerly incarcerated are viewed by their peers is social stigmatization (2020). Self-stigmatization is how the formerly incarcerated feel about themselves, often because of structural and social stigmas. They are ashamed of their history and work hard to keep it concealed from their peers, faculty and administrators; they also avoid engaging with others with criminal histories to not call attention to their own (Ott & McTier, 2020). Women often allow the crimes they have committed to drive how they self-identify (Sherman, 2017). This can lead to further stigmatization and cause them to fall back into old behaviors. Securing employment, connecting to the community, focusing on strengths and gaining confidence can lead to successful reintegration. External barriers and lack of knowledge on how to get out of default on loans, apply to college, establish financial aid, learn advanced technology and navigate the requirements of state supervision upon release contribute to anxiety and fear on how they may be perceived and judged this holds them back in their own heads and distracts them from taking those first vital steps toward their goals. Spotlight on Indiana: Barriers to higher education for incarcerated and formerly incarcerated students, by the Incarcerated and Formerly Incarcerated Women, focuses LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 34 on many external obstacles and their connections to internal barriers, such as stigmatization and PTPD (Bumgardner et al., 2019). Support networks are needed that begin working with women during incarceration who can then transition alongside them into re-entry assuring support in securing basic needs, housing, employment and continued education are foundational for successful re-entry as well as a catalysis for continued higher education for formerly incarcerated people (Bumgardner et al., 2019, p. 82). This support is crucial in helping increase capacity to overcome the barrier created by the stigma of incarceration which locks formerly incarcerated people out of opportunities and basic sustenance (Bumgardner et al., 2019, p. 82). Internal Barriers: Stereotypes & Stigma There are many articles about the external barriers with admissions, probation, financial aid, defaulted loans and countless others, but there is minimal literature on what may contribute to the internal barriers and the impact those internal barriers have on formerly incarcerated individuals, especially for women and mothers, who desire college. Societal stereotypes about justice involved people and the stigma attached to formerly incarcerated mothers can be devastating. Stereotypes and prejudices locks incarcerated and formerly incarcerated people out of myriad opportunities and basic human rights, not least of which is education (Bumgardner et al., 2019, p. 5). Challenges & Vulnerabilities Unique to Formerly Incarcerated Women & Mothers Womens Pathways to Prison Women go into prison and come out of prison at a more significant disadvantage than men (Rose & Rose, 2014). Women are often impacted by the war on drugs which has resulted in a substantial rise in incarceration rates (Sherman, 2017, pp. 18-19; Heath, 2009, p. 1), as they are likely to use drugs to cope with a history of abuse or resort to petty drug sales to support LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 35 themselves (Cobbina, 2009, p. 9). These mothers have unique treatment needs because many grew up in violent homes with parents who abused substances, and they likely have a history of physical and sexual abuse, which takes a noteworthy toll that is underestimated, especially when it comes to the impact on re-entry (Bell, 2020; Sherman, 2017; Cobbina, 2009; Heath, 2009). Half to 95% of incarcerated women experience trauma or violence prior to incarceration (Heath, 2009). Women were typically the sole caretakers of their children before incarceration and intend to return to the role upon re-entry (Sherman, 2017). Men often return to homes and family units their wives have maintained while they were incarcerated (Cobbina, 2009; Case et al., 2005), while women often do not have a home to which they can return and are faced with broken families and children, even legal and custody battles (Case et al., 2005). Men are likely to gain employment; women have a harder time finding a job that pays enough to support themselves and their children while re-establishing a home (Cobbina, 2009). Women also face feelings of hopelessness about re-entering society successfully. Cobbina claims that most mainstream research overgeneralizes mens experiences to women, making women invisible in criminal justice, leaving the re-entry experiences of women largely understudied and undertheorized (Cobbina, 2009, p 3). Womens pathways to prison have bearing on their pathway from prison to college (Cobbina, 2009). Womens Unique Challenges to Re-entry & Education While there has been a significant increase in female incarceration, reintegration continues to focus on men (Case et al., 2005). There are barriers that are unique to women and how much more difficult it is for women than men trying to re-enter, from finding housing to gaining employment (Garcia & Ritter, 2012). Womens pathways from prison back to the LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 36 community look different, and they lack resources. Women and mothers are unprepared to return to their communities post-incarceration, and their communities are unprepared to embrace them and all their special needs. Upon release, women communicate fear of discrimination in their communities and concern over scant support systems throughout the re-entry process. Many of the formerly incarcerated women in Parkers study self-describe as felons and felt labeled by their communities (2009). It is a label they carry with them in all aspects of life; they must reveal their history on job applications, and there are many jobs and careers they can never consider because of their felonies. The women face stigma when trying to find housing as well (Parker, 2009). The word felon comes up when applying for an apartment or home loan. Many end up in halfway houses after release, which they describe as being worse than prison. While some said they desired an education upon release and that the education they had helped them find value in themselves, some women said they did not think having an education would matter because the word felon was so large that they believed education would never wipe the label away (Parker, 2009, p. 58) that the stigma attached to being a felon would make education useless and that they would not be able to get a job anyway. Some study participants even described education as not helpful, useless, confusing, does not make a difference, survive without it, and not needed (Parker, 2009, p. 58). The most intriguing part of Parkers study design is that she splits the participants up into three groups based on education level at their time of release (Parker, 2009). Group 1 did not have a degree; Group 2 had an associate degree or close to it. Group 3 had a bachelors degree or higher and spoke to the importance of education. All the Group 3 participants agreed to the importance of education - one said that possession of earned college degrees was empowering, providing them with the ability to navigate incarceration and re-entryand overcome adversity LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 37 (Parker, 2009, p. 74). The women gave specific examples such as the ability to write a resume, create self-help packets and obtain the documents needed for various transactions in society. One of the participants shared her view on her education (Parker, 2009, p. 75): The higher your education is the better you can analyze and see what's real from what's not real. I can analyze what someone says and determine if this is true. I noticed other women in prison who were not educated, they did not know their rights. I knew my rights, I was still a citizen. Of all the needs of re-entry, women cite education as the highest at 79% (Garcia & Ritter, 2012). While it is crucial for women to take part in education programs (Rose & Rose, 2014), they are at a disadvantage because most programs inside facilities are for men (Case et al., 2005). There is substantial research supporting education-reducing recidivism and increasing the likelihood of employment; however, education programs in prisons are limited and outdated for incarcerated women which poorly prepares women for college and employment upon release. This, coupled with the internal obstacles of low self-esteem, the stigma attached to their crime and incarceration, and trying to re-establish relationships with lost children makes womens journeys much more challenging. Distinct Re-entry Challenges to Motherhood Post-Incarceration Women are more likely than men to be the primary care givers to their children, which bring a unique set of barriers; motherhood creates more obstacles upon re-entry (Mitchell & Davis, 2019). The demand to reunite with their children makes a mothers re-entry more complex (Gobena, Hean, Heaslip & Studsrod, 2022), and reclaiming their role as mother is an additional stressor. There is an expectation that they take on the role of mother but are also held to state supervision requirements and the mothers needs and voices get lost along the way. And parenting is more difficult due to the toll incarceration has on the children and family unit. LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 38 Children will intentionally distance themselves emotionally from their mothers out of fear their mothers will return to prison; the children exhibit a broad variety of emotions and behaviors, such as anger or clinginess, even engaging in their own drug use and other criminal acts. The formerly incarcerated mothers interviewed in Shermans study revealed that mothering after prison was far more difficult than they anticipated (2017, pp. 17-18). The guilt these mothers feel can be crushing. Sherman mentions maternal distress (2017). This can be impacted by the view of negative parenting due to their criminal history and socioeconomic status. This distress can be caused by trauma, abuse, dysfunctional relationships with a partner, mental health, and guilt and concern over the well-being of their children (Sherman, 2017). Society and familys negative view on them contributes to a lowered self-esteem (Gobena et al., 2022). Many of the women are stigmatized by male partners and the fathers of their children, which they described as a danger to their re-entry (Gobena et al., 2022, p. 12); they feel disempowered and have been humiliated by many professionals who are to be providing the support they need (2022). They feel tremendous remorse over not being a part of their childrens lives while incarcerated, even as far as to question their right to parent (Sherman, 2017, p. 83). The view on these mothers is so negative that they begin to become more vulnerable and view themselves as bad and unworthy. The more vulnerabilities, the less successful formerly incarcerated mothers will be in reentry (Sherman, 2017). Vulnerabilities and life experiences of these women often impact their criminal activity because many of them are young, poor, mothers and have little to no education and no employment, lacking job skills. These situational variables make it more difficult to return to their role of motherhood (Gobena et al., 2022). Five areas of comprehensive need identified for their re-entry success include (Sherman, 2017): childcare; health care (includes LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 39 mental health and counseling); housing and transportation; education, employment and on-thejob training, and social support. Studies show that childcare was the least provided program for these women. None of the programs studied sufficiently met the needs of the women post incarceration. There is a lack of programming to inspire and encourage formerly incarcerated mothers (Gobena et al, 2022), and the lack of resources and programs for women leave them unprepared for re-entry and puts them at risk (Case et al., 2005). Motherhood & Bad Moms: Social Stigma & Self-stigmatization They re-enter society with limited resources and are labeled as deviant and unfit for their failure to satisfy conventional standards of mothering (Mitchell & Davis, 2019, p. 423; Allen, Flaherty & Ely, 2010, p. 162). All their life experiences surrounding poverty, substance abuse, domestic violence and incarceration impacts how they view themselves as mothers (Mitchell & Davis, 2019). A mother who deviates from what society views as normal or acceptable for motherhood is deemed unfit or bad (Mitchell & Davis, 2019). There is this idea that good mothers should invest infinite time, money and emotional labor in raising their children (2019, p. 422). Our society devalues formerly incarcerated mothers, expecting unnatural sacrifices. Formerly incarcerated mothers are viewed as maternal outcasts in their communities (Mitchell & Davis, 2019, p. 423; Allen et al., 2010, p. 162). Allen et al explains that simply being unmarried, uneducated, poor and lacking support and resources creates significant barriers for these women they are invisible in their communities (2010, p. 162). These authors strive to understand the impact of maternal incarceration on the experience of motherhood through the eyes of the mothers (2010, pp. 160-161). Allen et al says that Deeply embedded in our cultural psyche is the notion of the idealized mother; typically middle class, married, educated, and with access to resources (2010, LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 40 p. 162). Allen et al (2010, p. 162) quotes Ferraro and Moe (2003, p. 14) that the ability to mother ones children according to social expectations and personal desires depends ultimately on ones access to the resources of time, money, health, and social support. These women are marginalized by so many factors. They are convicted criminals, viewed by society as social outcasts. Their multiple marginalities, combined with the stigma and shame of incarceration, renders this powerless population disposable in the eyes of society. They are dismissed as throwaway moms (Allen et al., 2010). Criminal activity is more socially stigmatizing to women (Case et al., 2005) because it automatically puts them outside the role society has established for women and mothers (Allen et al., 2010, Ferraro & Moe, 2003): Poor and marginalized women, such as the participants in our study, do not fit the idealized portrayal of motherhood. Consequently, they may be perceived as not only inadequate mothers but as inadequate women. They are also, by virtue of their poverty status and marginalization, the most likely to become involved in the criminal justice system and, therefore, more susceptible to having their maternal rights impinged upon. Within this long-established and widely accepted paradigm, motherhood becomes a privilege for certain women as opposed to a right for all women. (Allen et al., 2010, p. 162) Double Deviant Theory & Discrimination Rose & Rose address the double deviant theory that when women break the law, they also violate gender expectations, so they are discriminated against inside facilities, having less programs and services available; they are also discriminated against in their communities when they try to reintegrate (2014). This is the argument made by Case, et al. Women with criminal histories, especially including incarceration, face stigma the minute they step outside the traditional gender expectation of law-abiding (Case et al., 2005, p. 154). One woman feels like she is paying her debt over and over as she struggles to reintegrate while encountering barriers to success (Case et al., 2005, p. 154) and urges programs to educate communities about the discrimination endured by formerly incarcerated women and mothers. LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 41 This double deviant theory applies to motherhood and the stigma attached to formerly incarcerated mothers (Case, 2005). Patriarchal societies believe women can only find physical and emotional fulfillment in motherhood (Gobena et al., 2022), and this view of motherhood is a way to socially control women (Ferraro & Moe, 2003). Deviating from this recognized norm results in stigmatization and being labeled a bad mother (Gobena et al., 2022, p. 1); mothers are judged for prioritizing themselves or anything else that may take away from the obligations of motherhood (Gobena et al., 2022; Ferraro & Moe, 2003). Women who break from this ideological construct are targeted because they do not fit the standard. They face gender bias because they have not or do not sacrifice themselves completely for their children. Adding a history of incarceration only intensifies this stigma. Incarceration tarnished their identity as a good mother (Gobena et al., 2022, p. 9). To help formerly incarcerated mothers, it is necessary to move away from imposing the impossibility of patriarchal institutionalized motherhood and take a step toward a re-articulated mothering practice that understands mothers, mothering and motherhood beyond the expectations of what constitutes good mothering (Gobena et al., 2022; Green, 2015). Women experience fear upon re-entry fear cuts across motherhood, employment and belonging in the community (Parker, 2009, p. 48). Close to release, the women describe their anxiety and depression over the uncertainty they would face in their communities and a fear of not being accepted (2009). They felt lost without a sense of belonging and felt like they were not a mom according to the community in which they were entering (Parker, 2009, p. 67), which impacts how these women self-identify. Post Traumatic Prison Disorder Post Traumatic Prison Disorder significantly contributes to a diminished capacity to face the harsh stereotypes and judgment the women fear when entering the public sphere much less LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 42 the college environment. A formerly incarcerated scholar in Indiana shares her lived experiences and the impact of Post Traumatic Prison Disorder (PTPD) in her co-authored report, The Spotlight on Indiana: Barriers to higher education for incarcerated and formerly incarcerated students (Bumgardner et al., 2019). She explains that PTPD is distinct from other traumas because at its core lies extreme and prolonged deprivation; chronic dehumanization; myriad forms of violence, often experienced daily; a chronic cycle of grief and loss (Bumgardner et al., 2019, p. 70), making it difficult to maintain education that PTPD is the most powerful but least understood barrier to high education, stability, productivity, and happiness (Bumgardner et al., 2019, p. 71) and refers to education as a catalyst of transformation (p. 73) when she was at her lowest point during incarceration coming in from a history of trauma. Incarcerated women have different pathways to prison than men, often layered with abuse and trauma, and prison life impacts women differently; incarcerated women experience re-victimization/re-traumatization, as well as new forms of trauma through the carceral experience which led to PTPD (Bumgardner et al., 2019, p. 81). PTPD is not widely recognized yet and is a unique type of trauma. While there is research and work done by professionals on trauma, the best population to speak to the impact of incarceration and the effects of PTPD on capacity and re-entry is formerly incarcerated women. Formerly incarcerated women and mothers credit Shawanna Vaughn for devising the term Post Traumatic Prison Disorder (Brumgardner et al., 2019); Vaughn is a formerly incarcerated woman herself, who founded a non-profit, Silent Cry in Harlem, dedicated to providing care and services centered around PTPD (Nguyen, 2021). Vaughn says that remnants of mass incarceration derail successful re-entry and rehabilitation (Nguyen, 2021, para. 4). She authored the Post Traumatic Prison Disorder Act, Shawanna W76337 which has been LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 43 introduced to the New York State Senate. Vaughn says that PTPD is the trauma [that] starts before prison and lingers forever until there is help (Nguyen, 2021, para. 4). The Post Traumatic Prison Disorder Bill (Senate Bill 4872) calls for the following (2021, para. 8): (1) training prison personnel in basic trauma-informed mental health care, (2) policies for service provision to incarcerated individuals, (3) investments in behavioral healthcare services (e.g., screening, assessment and clinical interventions for trauma) and (4) connecting people with services post-release. The status of the bill is In Senate Committee (New York State Senate, 2022). Vaughn manages to set PTPD aside as separate and unique from other trauma disorders and is in need of a separate diagnostic category and separate forms of treatment (Bumgardner et al., 2019, p. 70). Prior to Vaughns advocacy for PTPD, prior literature seems to have lumped it under Post Traumatic Stress Disorder (PTSD). Just 10 years prior, there is no mention of PTPD in Heaths 2009 study, but she addresses PTSD which encompassed about everything from the PTSD experienced in the 1970s by Vietnam vets to those who experienced domestic abuse (Heath, 2009). According to an update (Bill Track 50, 2022), this bill requiring mental health services to incarcerated people with PTPD upon reentry died on December 31, 2022. Self-efficacy & Possible Selves The self-efficacy theory was first suggested in 1977 by a psychologist, Albert Bandura and applied to trauma traumatic events and trauma recovery; trauma victims were found to have lower self-efficacy levels (Heath, 2009; Bandura, 1977). A great deal of additional research has been done on self-efficacy since 1977. Relationships were drawn between PTSD in veterans and lower levels of self-efficacy. The same relationship was found between PTSD and selfefficacy in survivors of childhood sexual abuse. Trauma negatively impacts self-efficacy. In the late 1990s, it was found that as self-efficacy or internal sense of competency - increases, anxiety and PTSD decrease. Increased coping skills and enhancing a trauma survivors belief LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 44 that they can overcome the stress and trauma and regain control boosts their self-esteem and selfefficacy. Expanding self-efficacy is an intervention that could increase the emotional capacity of a trauma survivor and reduce the stress they feel in a given environment or circumstance. Selfefficacy work with trauma survivors is really about the survivors perceived ability to cope with and manage a given stressor or anxiety in a given situation. An individuals inability to increase self-efficacy could result in being ineffective in various areas of life. Substance Abuse and Mental Health Services Administration (SAMHSA) does address low self-efficacy in formerly incarcerated women which can be caused by trauma, financial insecurity and the trauma of being incarcerated, but all that is offered by way of support is peer recovery counseling (2020). Bells qualitative study focuses on incarcerated and formerly incarcerated women in the United States, specifically the State of Arizona and how to provide more support to this population at the university level to better prepare formerly incarcerated women for college (Bell, 2020). Bell examines Possible Selves, which is the theory that a persons behavior is largely determined by what they think they will become, what they would like to become, and what they fear becoming (2020, p. 7) and how this may affect decisions of formerly incarcerated women about attending college with the end goal of developing a participant-informed intervention and provide program recommendations to universities (Bell, 2020, p. i). Her intervention was the College After Prison Program (CAP). Her hope for CAP was to collaborate with formerly incarcerated women to provide needed information and support for students on the college process and the barriers as they have experienced them (2020). A focus of CAP was to increase the participants self-efficacy, but Bell acknowledges that the lived experiences of the participants influenced the workshop and how it was received. LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 45 Bells study explores how universities can better support formerly incarcerated women by clearing paths through bureaucratic barriers, creating targeted programming and outreach (2020). Bell also explores the womens fears of delving into their pasts to move forward and their regret over their lost possible selves (Bell, 2020, p. ii). Increasing a persons college self-efficacy as a motivating factor is at the core of Bells study (Bell, 2020, p. 7). While the literature reveals numerous structural and social barriers unique to women and mothers, the most significant roadblock to pursuing college is their own struggle to believe in themselves and view themselves as college material (Bell, 2020, p. 7). The women who participated in Bells study shared their past experiences with education and their feelings of hating school and not belonging (2020). One participant shares her feelings on school at an early age (Bell, 2020, p. 65): I hated school when I was in grade school and high school. I was not a popular kid and I just, I didnt like school. I didnt like learning. Didnt apply myself. And then in high school it was more about, you know, trying to fit in and doing like the in crowd did. I never really fit in. Not fitting in lead to viewing school as a waste of time and feeling self-conscious and insecure affected academic performance, which lead to believing in their inability to be good in school. (Bell, 2020) Another participant said she never developed a deep connection with the educational system and is still struggling to place herself in it (Bell, 2020, p. 66). Many of the women who participated in this study shared similar stories of not belonging and stories of childhood traumas, from abuse and discrimination to losing a parent to incarceration (Bell, 2020). From teachers who criticized handwriting and overly strict, religious parents who cut all relationships with teachers and peers and home schooled, to falling in with the wrong crowd who encouraged powerful negative emotions free reign (Bell, 2020, p. 68), these participants stories are LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 46 examples of how their pathways lead them away from school, many times to substance abuse, incarceration and the gradual decreasing of self-efficacy over time. If their college self-efficacy can increase, then the structural barriers do not seem so unrealistic or out of reach. Bells CAP Workshop begins with an Education Journey Map and a Possible Selves Questionnaire, allowing the women to face their past experiences with education, explore where they see themselves within the education system and discover options for future education and how institutions may support them along their journeys (2020). Self-efficacy, goal identification, financial literacy, and career pathways are strong themes threaded throughout the workshops six modules. Bell immerses herself in the workshop activities with the women to build trust. (2020) Images of formerly incarcerated students have of themselves, whether positive or negative, often control the decisions they make (Bell, 2020). Bells intervention and CAP Workshop is rooted in Possible Selves theories. The possible future self is influenced by internal self-efficacy and limited by the perceived belief about what society thinks is feasible. The participants in Bells study must understand and explore their past educational selves, their present educational selves and develop a plan for their future educational selves to navigate systems, overcome oppression and move past the stigma. If they can increase self-efficacy and envision a positive future self, it can motivate behavior, just as a feared future self can also motivate behavior and decision making (Bell, 2020, p. 30). If formerly incarcerated students or any non-traditional students - can fully recognize the selves, they can visualize alternatives to behaviors that may lead to recidivism. To increase college self-efficacy, the self must focus on who they want to become and what they want to achieve as opposed to who they think they are and what they think they can achieve, or not achieve. Building self-efficacy can be done through the establishment of small goals and working toward progress on those goals; something as small LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 47 as working through the writing process on a paper demonstrates they can learn and are capable of college and makes them feel empowered. Sherman (2017, p. 16) addresses the need for an empowerment approach that identifies an individuals capacity for change and making positive choices. Shermans study addresses the theme of strengths identification (2017). The formerly incarcerated mothers in the study identified the importance of internal strength what they found within themselves and the external resources to combine for success. All the women interviewed identified inner strength as a contributing factor to their re-entry success. They identified all the positive attributes they had to contribute to society. These mothers have found a way to lay their past to rest and focus on who they are now, not who they were at the time of their crimes. Stigmatization on College Campuses Fears of the Formerly Incarcerated Taking Roll: College Students View of Their Formerly Incarcerated Classmates addresses one specific obstacle that formerly incarcerated people face when pursuing a college degree: the stigma and trauma it can cause to formerly incarcerated people, especially at institutions of higher education (Binnall et al., 2021). Formerly incarcerated people live with the mark of a criminal conviction, such attitudesif presentcan be internalized (Binnall, et al, 2020, p. 2; Cooley, 1902), hindering their ability to fully reintegrate and transcend the criminal label (Binnall, et al, 2020). The Looking Glass Theory, first devised by sociologist, Charles Horton Cooley, applies to the inner struggle faced by the formerly incarcerated (Nickerson, 2021). Cooley argued that people form their self-identity by imagining how they appear to others, how others may judge them and how those judgments impact how others feel about them (1902; Nickerson, 2021). LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 48 Justice involved individuals fear being mistreated. While teaching class last year at the Indiana Womens Prison, one of my students expressed this exact concern; she was preparing to be released in November 2021 and was thinking about finishing her degree online out of fear of how she may be treated on a college campus (L.H., personal communication, 2021). These fears reduce justice involved womens potential for academic achievement and motivation, possibly impacting graduation (Binnall, et al, 2021; Halkovic & Green, 2015). The return to higher education can be traumatizing (Binnall, et al, 2021) for anyone with a criminal history, and there is little research on how college students feel about their justice involved peers. This uncertainty about how they will be perceived only increases the fears, insecurities and anxiety of formerly incarcerated and justice involved students. Peers, Faculty & College Administrators: Their Feelings on Justice Involved Students & Intergroup Contact Theory The Binnall et al study focuses on how non-justice involved students feel about sharing campus and classrooms with formerly incarcerated students and the power of prejudice (2021). They explore how the role of intergroup contact theory applies to a college campus and the immersion of formerly incarcerated students. The authors study a random sample of 185 college students, and the results showed that the more non-justice involved students are engaged with justice involved students the more frequent, close contact with justice involved students - the more accepting they are and more likely to hold more positive views on the population. This research indicates that stigma correlates with lack of exposure to justice-involved classmates. But this stigma extends beyond their fellow peers and classmates. Formerly incarcerated students fears are legitimate: campus stakeholders often harbor prejudices about students with an incarceration history (Binnall et al., 2021; Copenhaver et al., 2007; Ott & McTier Jr., 2020). Binnall references other studies that assess the attitudes of LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 49 faculty, and the data shows they often hold more negative feelings toward formerly incarcerated students than other students (Binnall, et al, 2021; Copenhaver et al., 2007). According to Ott & McTier, faculty attitudes and behaviors toward justice involved students have received little focus from researchers, and faculty members are critical socializing agents (2020, p. 298) who impact whether students can integrate into their college environments and stay through to graduation. Faculty are critical to student success, and when students perceive faculty attitudes to be negative, disrespectful or non-welcoming, it impacts their motivation and confidence level (Binnall et al., 2021). Often, administrators question depending on the crime - whether formerly incarcerated people can be rehabilitated (Binnall, et al., 2021). The stigma attached to formerly incarcerated people can be paralyzing (Kirp, 2021, para. 11): Formerly incarcerated students may well encounter a frosty reception on campus. College administrators and state officials may keep a close eye on them. Some institutions refuse to allow them to live on campus and bar them from participating in extracurricular activities. (Kirp, 2021, para. 11) Ott & McTier surveyed over 200 faculty members and found that their attitudes about students with a criminal history were more negative than their feelings about their other students (2020). Students with criminal histories encounter an uninviting campus environment and face discrimination from all directions other students, professors, administrators and campus police (Ott & McTier, 2020; Dreger, 2017). Dreger provides a few examples from their studys interviews with formerly incarcerated students. One of Dregers study participants said he was pulled aside by instructors and given a verbal warning that he would be removed from the program if he decided to revert to old behaviors (2017, p. 192). Dregers participant said (2017): I was given the little lecture about, Well, if you do decide to you know, to revert . . . LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 50 we will be on you and we would escort you [out]. You would be basically done (p. 192). Another participant in Dregers study shared his experience after he revealed his incarceration history (2017, p. 197): They look at you differently afterwards. Theyre like, Oh wow, how long were you in? The next thing you know, youre just . . . that guy. It just makes things awkward (p. 197). Another participant added that people look at you differently. I could care less what people think about me, but sometimes its just the . . . being uncomfortable that goes along with it" (2017, p. 197). Others shared how they were excluded from campus activities. As more are recognizing the value of education for this population, more scholars and researchers are focusing on the experiences of formerly incarcerated students in post-secondary environments. College students stereotype students with criminal histories, citing a fear for the safety of themselves and their belongings and resent that justice involved students are privileged and special, getting free access to resources and education that they did not have and believe incarcerated individuals were damaged, dangerous, aggressive, and ignorant (Ott & McTier, 2020, p. 299). Such social stigmatization (2020) can diminish over time just with exposure and understanding. The more familiar one becomes with a person who committed a crime in their past, the more stereotypes get reduced about the justice involved (Binnall et al., 2021; Ott & McTier, 2020). Binnall et al references Gordon Allports intergroup contact theory which proposes that the more time a majority group spends with a stigmatized group, empathy will increase (Binnall et al., 2021; Allport, 1954). Allports intergroup contact theory comes from his belief that prejudice is learned when a particular group is assigned objectionable qualities in society (1954). There is evidence to support intergroup contact theory regarding formerly incarcerated people the more exposure to LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 51 this population, the more the majority group softens (Binnall et al., 2021). Quality of contact and amount and length of contact certainly play a role in level of stigmatization and feelings toward the stigmatized population the more time spent, the more empathy is developed (Binnall et al., 2021). Lived Experiences of Formerly Incarcerated Students & The College Process One of the formerly incarcerated authors of the Lumina Report shares her experience returning to Indiana University Purdue University Indianapolis (IUPUI) while on house arrest (Bumgardner et al., 2019). She was called out of her tour group during new student orientation and sent to meet with the Dean; there was no reason for special attention she had already revealed her criminal history and was accepted to the university. By the time she was able to rejoin the group, she missed a lot of valuable information and was not able to connect with the other students, who got to know one another while she was pulled out to visit the Dean. She shared, I would like to work with my fellow students on collaborative projects. But I'm, I'm too embarrassed to disclose to them that I am on house arrest. So, it's constantly in my mind, make sure nobody sees your ankle monitor, make sure that you don't talk about the fact that you were incarcerated (Bumgardner, et al, 2019, p. 76). This student thought being accepted to the university would be the primary hurdle, but administrators singled her out and subjected her to continued scrutiny. Her experiences on campus became a constant reminder of her past, her felonies and her differences from her peers; when she rejoined her tour group, she immediately knew this was going to be a different experience for me than it is for the average college student. And that was really heartbreaking, because I'm much more than just my felonies. (Bumgardner et al., 2019, p. 77) LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 52 One of the participants in the Halkovic study explained how they felt when walking into a college classroom (2015, p. 769): I think that entering a classroom as a person who is formerly incarcerated, you automatically feel different. You feel that youre different than everybody else and you do wonder about the other students where theyre at and if they can actually tell that you are formerly incarcerated. Its like you wear it like an invisible coatyou feel it and you wonder if anyone else can see it and tell. (Halkovic & Green, 2015, p. 769) It is common for formerly incarcerated students to refer to their identity as clothing (Halkovic, 2015). Articles of clothing can be put on and taken off, as they put on and take off different identities to fit into different spaces and stay safe. This is unfair to the students but also unfair to the academic institution when formerly incarcerated students feel pressure to hide important parts of their lives, their peers and faculty miss the opportunity to learn and grow from their lived experiences and perspectives on life and community issues. Coping with the Stigma There is research that suggests that society maintains negative views on individuals who have spent time in jail or prison, and formerly incarcerated students go to a variety of lengths to cope with fear of judgment and manage the stereotypes they may face because of their criminal histories (Binnall et al., 2019). Students are torn between concealing or disclosing their criminal histories, knowing that judgment and stigma come with disclosure, but also that honesty can form the basis of trusting relationships and networks (Halkovic & Green, 2015). Some may choose to bravely disclose the details of their history, while others do whatever it takes to bury it and blend in with their peers (Binnall et al., 2019). Others cope by not recognizing or acknowledging the difference between those with a criminal history and those without. The desire to be part of the in-group and not discriminated against as a member of the outgroup causes them to deemphasize the difference between us and them (Binnall et al., 2019, p. 5). LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 53 University Barriers & The Role of the Institution Few dispute the benefits of pursuing higher education, but the reality of formerly incarcerated women achieving this is more complicated. Universities present barriers, some of which they may not be aware, that scare away formerly incarcerated students before they have a chance to enter the classroom (Bumgardner et al., 2019). They have little access to support before they even begin the application and enrollment process they have little connection to college campuses and feelings of familiarity and a sense of belonging (Bumgardner et al., 2019, p. 65). When formerly incarcerated students do enroll, they struggle to get guidance from academic advisors and often cannot transfer credits from college courses taken while incarcerated (Bumgardner et al., 2019). They are limited in access to peer mentors and university resources. When universities lack dedication to connecting with formerly incarcerated students, pathways to re-enter education can be poorly designated or lacking (Bumgardner et al., 2019, p. 65). The reputations of universities and colleges can intimidate formerly incarcerated students who may have an away response based on public images of whom the university serves, who is on the faculty, when and how it shows up in the community, and who enrolls on campus (Bumgardner et al., 2019, p. 65). Many universities are ill equipped to recruit, service and support formerly incarcerated students. It may just be a lack of understanding and knowledge. Formerly incarcerated students are simply not on the radar. Recommendations from Formerly Incarcerated Women The study Spotlight on Indiana: Barriers to higher education for incarcerated and formerly incarcerated students offers recommendations from formerly incarcerated women based on their own lived experiences. The authors examine the impact of incarceration on LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 54 educational prospects and outline what would help this population build the capacity to face the stigma of incarceration offering wrap-around re-entry services and support networks (Bumgardner et al., 2019). These are significant adaptive challenges that the recommendations can only help to make progress, not offer fixes or solutions to change people or systems. The women recommend hiring faculty, staff and leadership roles who have a justice involved background to help increase the comfort level of the formerly incarcerated population (Bumgardner et al., 2019). This would help universities commit to a true culture shift to make college more assessable to the post-incarcerated populations. This would require the universitys commitment to embrace justice-involved people at all levels (Bumgardner et al., 2019, p. 83). The authors encourage colleges and universities to create a reverse pipeline from the most impacted communities to campus (p. 83) and to announce their commitment publicly to their communities, as well as expanding partnerships and networks to help with other external barriers that students face, such as housing, jobs and health care. One of their recommendations, which inspires my intervention, focuses on building designated, uncluttered pathways for the formerly incarcerated to enter campus and experience college, not just as students but also as workers, and inviting students to design the pathways, with all information in one place, sequenced steps, and clear, individualized support (Bumgardner et al., 2019, p. 83). Bells study explores how universities can better support formerly incarcerated women by clearing paths through bureaucratic barriers, creating targeted programming and outreach (Bell, 2020). Sharing alternative narratives across campus through scholarship, panels, and guest speakers, creating welcoming spaces for incarcerated students across campuses and being intentional publicly about the support of incarcerated students are all steps that can be taken to change the dominant narrative (Bumgardner et al., 2019, p. 84). They also recommend LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 55 providing college classes, educational programs and lecture series inside prisons, as well as other ideas involving incarcerated populations that may lay better groundwork for pathways to college upon release (Bumgardner et al., 2019). College Programs Dedicated to Justice Involved Students Ott & McTier (2020) recommend the development of programs on campuses to allow campus students and stakeholders to engage with formerly incarcerated students. This would inspire discussions about the unique contributions these students can bring to a college campus community (2020). San Francisco State and Rutgers are mentioned for building peer-to-peer support networks, mentoring programs and other support programs for college students with criminal records. Programs at institutions and organizations in other areas of the country are doing wonderful work to create college opportunities and support structures for formerly incarcerated and justice involved people which can help shape our direction in Indiana. UC Berkeleys Underground Scholars The University of California Berkely is home to the Berkeley Underground Scholars. Their mission is to build a prison to college pipeline for incarcerated, post-incarcerated and system impacted individuals (About, 2020). Underground Scholars was founded by formerly incarcerated and system-impacted persons in 2013 and receive a great deal of support from UCBerkeley and other campuses in the UC network. A California state senator helped the organization receive state funding. The Underground Scholars focus on recruitment, retention and advocacy and are housed on UC Berkeleys campus. All these initiatives are equally important and crucial for incarcerated students success; however, I am particularly drawn to the retention arm which includes financial assistance, tutoring, advising, employment and ties to LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 56 community involvement (Berkeley Underground Scholars, Our work, 2020). A team of tutors and advisors work with the students toward academic success and assist in applying to graduate schools and law schools. Their financial aid advising is catered to the formerly incarcerated population, and they offer various programs focused on leadership training and opportunities. In May 2020, the recruitment department launched a new, remote Incarceration to College program in juvenile facilities (Berkely Underground Scholars, Our work, 2020). There is a transfer support program which helps formerly incarcerated community college students transfer to UC. Their ambassador program operates like a mentor program, so formerly incarcerated students have peer support, particularly in the community colleges. The Advocacy division of their work focuses on removing barriers to college and employment, as well as support for formerly incarcerated students who are on parole or probation. They advocate for policies to improve access to higher education and work to ensure campus is safe for formerly incarcerated students. Danny Murillos educational path began in prison and continued with University of California, Berkleys Underground Scholars which he co-founded (Kirp, 2021). Murillos journey and vision is dedicated to inspiring formerly incarcerated people to pursue a college education. Kirp addresses the damage done by the removal of Pell and the opportunity created by its reinstatement, as well as the obstacles formerly incarcerated scholars face on their pathways to higher education, such as admissions policies and rejection by many college campuses (2021). Murillo authored The Possibility Report, in which he makes a convincing economic and moral case for encouraging formerly incarcerated students to go to college (Kirp, 2021, para. 3). Murillos report serves as a blueprint for formerly incarcerated scholars who want to pursue college (Murillo, 2021). The report provides an overview of the condition of institutions LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 57 of higher education when it comes to educating and servicing incarcerated and formerly incarcerated people. The report addresses barriers and opportunities faced by formerly incarcerated people pursuing higher education in California. The report provides recommendations to help college campuses and the state of California break down these barriers and establish more opportunities for formerly incarcerated students to improve their lives and the economic health of the state. While there are significant differences nation-wide between colleges and states, this report identifies universal challenges that transcend across state lines, such as parole and probation not prioritizing post-secondary education and state supervision requirements creating barriers to educational goals. Students straddle two employment problems: finding work and juggling work and school (Murillo, 2021, p. 14). Colleges need more targeted student support; advisors lack knowledge on career pathways for formerly incarcerated students, and there are limited and inconsistent services, leaving formerly incarcerated students as their only advocates. (Murillo, 2021) Targeted student support includes help retrieving transcripts, advising, an understanding of financial aid, registering for classes, and assistance finding housing, mental health counseling and legal support while in school (Murillo, 2021). This targeted support is addressed in Bells study to fill in the education gap for the formerly incarcerated (Bell, 2020). Once on campus and enrolled in courses, students need intrinsic support (Murillo, 2021, p. 18). Formerly incarcerated students face so many obstacles that if they do not have the appropriate support, they will drop out. The students interviewed in The Possibility Report often lived in halfway houses with no work, no money and no transportation; they struggled back and forth between meeting parole or probation requirements while re-establishing relationships with their children. Even their ages returning to college induces fear and insecurity (Murillo, 2021, p. 18): LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 58 I was embarrassed by my age to be going back to school. I thought everyone would judge me. My school at the time didn't have a program for formerly incarcerated people. I bounced off the walls asking myself what I can do with my major. I have all these felonies and didn't know what I could do. I almost quit. (Murillo, 2021, p. 18) Students said that peer-to-peer mentoring would do wonders, but so few of these programs exist. Not only does the peer support help navigate the external obstacles, but it helps to overcome the cultural, psychological, and social barriers they encounter on a college and university campus (Murillo, 2021, p. 20). One student shared that a support network is important. It is helpful to see your brother walking in your direction and being able to say hi to somebody with a shared experience. That camaraderie is important. Some could encourage me and say no, you sit in the front of the class not the back (Murillo, 2021, p. 20). Support from faculty and administrators is equally important in helping formerly incarcerated students feel welcome on campus and combat the stigma (Murillo, 2021). Funding should go toward creating support service programs to serve this student population, including on-campus mental health services that address the traumatic experience that is incarceration, and an effort should be made to offer work-study opportunities. A formal onboarding program is also recommended and an ally safe zone training so that faculty and staff are better equipped to service formerly incarcerated student populations (Murillo, 2021). The creation of these support services at some universities is student driven and often not an institutional initiative. Project PROVE Case et al (2005) focus on one post-release program called Project PROVE (Post Release Opportunities for Vocational Education) which addresses the special needs of formerly incarcerated women as they re-enter society and continue their education. This study describes our societys climate as being increasing[ly] unsympathetic to formerly incarcerated womens needs (Case et al., 2005, p. 147). Project Prove provides services to women released from LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 59 Michigan state prisons and follows a model of reintegration that offers greater effectiveness for life stabilization, quality of life and recidivism reduction (2005, p. 149). While the program begins with the women inside the facility, it extends their program support and services upon reentry, which most inside programs do not do. Aside from helping them to enroll in college or vocational schools, the program recognized other needs of post-incarcerated women, aiding with housing, relationships with family and children and substance abuse treatment. PROVE recognized the need to clear external barriers and increase efficacy to get the women on a path to education. Lack of housing and homelessness, gender discrimination, little support from the childrens fathers, meager job opportunities, struggles with addiction and substance abuse history all have a depressing impact on an individual's motivation (Case et al., 2005, p. 150). These womens needs far exceed simply getting into class (2005, p. 150). Their biggest selfidentified barrier was low self-esteem. Self-esteem, self-image and psychological obstacles intersect the external barriers and are just as important to address. (Case et al., 2005) Educational goals were the primary reason the women chose PROVE, and many were dealing with defaulted loans (Case et al., 2005). PROVE provided educational support and financial assistance with book, lab fees, transcript requests, tutoring, grade monitoring, grant applications, and an understanding of how school administrations work, as well as noneducational support in the form of monthly meetings with peers, counseling, jobs, daycare, and housing. Distinct about PROVE, it provides a safe environment where women are working only with other women and where there is increased understanding of the challenges faced by women who have been incarcerated (Case et al., 2005, p. 153). The dedication demonstrated by these programs and their leaders is motivation to make progress on educational pathways for students with incarceration experience and justice LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 60 involvement. Some of their work informed my research questions and intervention to explore the lived experiences of formerly incarcerated mothers in Indiana and what they perceive to be the most hindering obstacles on their journey to college and how fear, anxiety and self-esteem may be the most significant barriers to overcome. LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 61 METHODOLOGY & DATA COLLECTION The mothers at Indiana Womens Prison and the formerly incarcerated mothers and students were the inspiration. The following research questions motivated the development of the intervention and guided this study: What are the experiences of formerly incarcerated mothers in their journey to pursue college? How do the formerly incarcerated mothers perceive external obstacles to hinder their capacity as they pursue post-secondary education? How do the formerly incarcerated mothers perceive the stereotypes about mothers with criminal histories and how does the stigma impede their capacity to return to post-secondary education? How can Pre-College Workshops help formerly incarcerated mothers build capacity within themselves to overcome the external barriers blocking their pathway to college? How can a Pre-College portfolio help this population better navigate their return to college and face the stigma? Definitions of Terms Post-secondary education, College, Education are all terms used interchangeably for any post K-12 education at a university or college, any institution of higher education. Formerly Incarcerated Individual or People refers to an individual or group of people who have served time in the carceral system. Justice Involved Individual is more humanizing language for individuals who have had interactions in the criminal justice system, as a defendant, at any level; a justice involved individual may or may not have incarceration experience. LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 62 Incarceration experience refers to the lived experiences of incarcerated and formerly incarcerated people. Recidivism refers to an individuals relapse into criminal behavior leading to further or re-involvement with the criminal justice system and/or re-incarceration. Double Deviant Theory applies when women break the law, they also violate gender expectations, hence doing two things wrong from societys perspective. Post Traumatic Prison Disorder (PTPD) is a unique trauma, distinct from other traumas, which is experienced because of incarceration. Identity is made up of all the memories, experiences, values, beliefs and relationships around which we view ourselves and create our sense of self how we self-identify. Possible Selves is a theory that explores the past, present and future self to increase selfefficacy and the idea that our behaviors are determined by our belief in our ability to accomplish whatever it is we set out to accomplish. Self-efficacy is ones internal sense of competency - a trauma survivors level of belief that they can overcome the stress of a trauma and regain control of their self-esteem; Selfefficacy Theory is a persons belief in their own capacity and confidence to take control of decisions and behaviors that produce a desired outcome or result. Structural Stigma includes any policies or procedures in place at an institutional or within a system that restrict an individual or group of individuals by limiting their opportunities. Social Stigma is discrimination against an individual or group of people based on a perceived idea about them that stimulates fear, anxiety and low self-esteem within the stigmatized group. LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 63 Self-Stigmatization occurs when one internalizes the negative perceptions of others which leads to shame and low self-efficacy and can be perpetuated by continued structural and/or social stigmas. Intergroup Contact Theory says that the more time a majority group spends with a stigmatized group, the more the majority groups anxiety will decrease, and their empathy will increase. Conceptual Framework Phenomenological Method This phenomenological study examined the stigma surrounding motherhood and how mothers criminal history may have impeded their pathway to college through the lens of formerly incarcerated mothers. Through this research, the hope was to find out how formerly incarcerated mothers feel about motherhood and their criminal histories and any challenges it has created on their pathways to pursue post-secondary education and re-entry into their communities. The hope was to uncover what may contribute to their challenges and which services and pieces of support may have helped/will help them to make progress facing perceived stigma which has hindered and/or continues to hinder their movement. My theory has been that mothers face additional obstacles upon returning to their communities and pursuing college, which is, in part, due to societys traditional views on motherhood and the stigma attached to justice involved people, especially moms who enter a traditional institution of higher education, which is still very much an elite system. The purpose of the phenomenological method is to make sense of human lived experiences. A phenomenological research method brings challenges because the researcher must remain objective in the descriptions and interpretations of the lived experiences of their participants (Wilson, 2015). Wilson references the original work of Edmund Husserl and Martin LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 64 Heidegger and discusses the comparison between phenomenology as philosophy v. phenomenology as methodology. Eddles-Hirsch explains its root in philosophy can be problematic for researchers, creating uncertainty on how to use phenomenology as a methodological framework (2015, p. 251). The phenomenological researcher cares more about the essence of the [lived] experience (2015, p. 252) and what is at the heart, the core of those experiences - which is why the results section of the study is dependent on many direct quotes from the participant mothers; continuous recognition is given to the womens advice on how to improve the workshops and portfolio, which embraces the phenomenological approach. In this study, the phenomenon is how the formerly incarcerated mothers have experienced the stereotypes of motherhood and the double stigma of their incarceration and how they have experienced education with a criminal history and how that has impacted self-efficacy. To better understand the feelings and experiences of the mothers is to better understand the society in which we are all living. The focus was on the participant mothers and the world in which they live and share with all of us. It becomes more complex because phenomenology is not one single approach, it is made up of three different philosophies (Eddles-Hirsch, 2015). The phenomenological process has three steps. Describing how the participants truly feel and experience the phenomenon, and, in this study, how they experienced the intervention is crucial and required the researcher to set aside preconceived notions of how they might think or feel. The first step - a process known as bracketing (or reduction process) - allows the researcher to set aside their own knowledge and beliefs to focus on the participants described experiences (Eddles-Hirsch, 2015). Imaginative variation then allows the researcher to identify themes and see a variety of perspectives. Finally, the researcher develops a statement that uncovers the essence of the formerly incarcerated LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 65 womens feelings and lived experiences - in this case, the core spirit of the mothers. The true essence can never be captured because it only represents the perspective of the researcher at any given moment through a specific lens of their study participants (Eddles-Hirsch, 2015, Moustakas, 1994). Researcher as Instrument & Anticipated Researcher Bias My personal interest in this topic began in 2016, when I started teaching English at the Indiana Womens Prison. Getting to know the women, many of whom were mothers, changed my perspective on justice involved women and opened my eyes to our societys views on women, motherhood and criminal behavior and incarceration. The more I worked with these women and mothers and after the pre-diagnostic interviews for a class in Fall 2021, I began to develop a new empathy for them and bias against those in our community who discriminate against this population against those who disagree with the importance of college in prisons and creating pathways for formerly incarcerated women and mothers to complete college upon release. As a woman, I am aware of my biases against patriarchal society and biases in support of women as women, not women as mothers, and womens rights to career and education that a womans worth is not rooted in her decision to be or not to be a mother. Working in higher education for 16 years, I acknowledge the importance of a degree, which could also lead to bias in a belief that education is the most important thing, and how making college more attainable to formerly incarcerated women will positively impact our communities. While I had little previous professional experience in qualitative research prior to this study, my involvement in the academic research and publishing program, in the Pre-College Program, at the prison has stimulated personal conversations, observations and research on these topics. My sympathies are entirely with the formerly incarcerated mothers which could have interfered with my interpretations of the literature, as well as my interpretations of their lived LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 66 experiences, and lead to bias. One of the participants has known me for several years which could have impacted her comfort level in the workshop series of the intervention more so than that of the other participants. To accommodate this, other Marian University staff and faculty assumed leadership roles in Workshop #1 of the intervention and contributed observations, interpretations and feedback. Participant Selection All participants had the desire to return to college. Participants were chosen by two methods: a convenience sampling strategy was used due to time constraints. Convenience sampling does not require random sampling and allows for convenient selection of participants who are pleased to be a part of the research without the need to examine the full population (Qualtrics, 2022). Having worked and volunteered in education programs at Indiana Womens Prison in Indiana, I relied on my network with educators in prison programs, professionals at other local universities, and formerly incarcerated women in Indiana. To increase my participant pool beyond participants chosen by convenience sampling, I also used the Voluntary Response Sampling. Professional colleagues released a request for volunteer research participants on various social media sites and through various organizations and non-profits in Indiana to participate in this study, who were selected randomly based on interest and availability. See the flyer distributed as a Callout for Research Participants in Appendix G. Data Collection Methods Data was collected in several ways: pre-intervention questionnaires, non-participant observations of Workshop #1 and her notes, participant notes and observations of Workshop #1, Workshop #2 group debrief of Workshop #1, and post-intervention individual interviews with the participants. All participants were asked to complete a questionnaire prior to Workshop #1 of the intervention. Three of the four participants completed and submitted a questionnaire, which LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 67 can be found in the Appendices. One potential participant completed and submitted a questionnaire but did not show up to Workshop #1; this data was not used. Data collected from the questionnaires helped to guide the contents of the intervention tool: the Pre-college Portfolio. Post Workshop #1, the group of participants engaged in Workshop #2, which was a debrief of Workshop #1 via Webex which was recorded for transcription. Then, participants were interviewed individually. All interviews with individual participants were semi-structured, conducted via Webex and recorded for transcription. Transcripts are included in the Appendices; some names are redacted for confidentiality. It could be perceived that I may have had influence over one of the participants who is currently enrolled as a student in Marian Universitys MAP Online Programs of which I serve as Director of Educational Services. She was not a student in my online classroom; however, I was involved in communications between her, her advisors, professors and other appropriate Marian University staff to provide educational services and support. None of the participants were incarcerated, but one was under supervision by the State of Indiana and received permission to participate in the study and intervention, including travel out of county to and from Workshop #1. Data Collection Analysis Methods Workshop #1 was observed by a non-participant, staff volunteer who took notes on the day and shared those notes after Workshop #1. I also took notes throughout the day. Workshop #2 debrief and one-on-one interviews were conducted via Webex and recorded. The Webex recordings were downloaded, saved and transcribed. For categorizing data, the study and data analysis was to be informed and guided by Johnny Saldanas (2021) The Coding Manual for Qualitative Researchers; however, with only four participants in the study, coding was not necessary, as not as systematic data gathering was rather small scale, therefore LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 68 manageable. Had there been fifteen participants as originally intended, I would have used Emotion Coding and Narrative Coding. The selection of themes was also manageable and guided by Saldana (2021). Themes were chosen based on participants lived experiences and theories from the literature review. Themes were also chosen that helped to answer the research questions (2021). According to Saldana (2021, p. 258), there is no precise formula on number of themes selected and can consist of behavior descriptions and content from participants stories and lived experiences. Theme selection was based on the following considerations which are also addressed by Saldana things to consider when choosing themes: repetition of ideas, theory related material, and missing data, which can be applied specific to barriers specific to single mothers (2021). The author says that tensions in the data are excellent opportunities for constructing themes (Saldana, 2021, p. 259). One example given was to answer questions like the following (2021, p. 259): what worries or concerns are the participants expressing? and what do the participants find intriguing, surprising or disturbing? Both questions helped me to generate themes and gain a deeper understanding of lived experiences, which is at the root of the research questions which address what it is like to be, to have, or to live (2021, p. 268). Themes were chosen in hopes of capturing the phenomenon being study in this case, in this study, the phenomenon is how the formerly incarcerated mothers have experienced the stereotypes of motherhood and the double stigma of their incarceration and how they have experienced education with a criminal history and how that has impacted self-efficacy. The most significant challenge was organization due to the themes bleeding into one another and how connected the data is. All participants were Indiana state residents. Consent forms for each stage of the intervention: Workshop #1, Workshop #2 debrief and individual interviews were provided to all LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 69 participants via e-mail with request for signature. All consent forms were signed and returned and are available in Appendices. For confidentiality of the participants, they were asked their preference on how they are referenced in the research; the participants are referenced and quoted by first name. Anticipated Limitations & Unexpected Limitations It was anticipated that my chosen population could limit me in several ways. Reaching out through social media channels, organizations and non-profits and asking for volunteers does not guarantee racial diversity. It was not as limiting as anticipated; the final participants included two white women and two black women. There was also an anticipated concern that those who agreed to participate could later experience a conflict and not be able to participate at all and/or be unable to follow through with the Workshop #2 debrief and/or follow-up interviews. Several participants committed to Workshop #1 on Saturday, April 15, 2023, then had to decline due to a conflict, primarily due to conflicts with their childrens sports and activities and/or childcare issues; they did not want to miss the first soccer game of the season, school competition, picture day, etc. This was a more significant limitation than expected. I was asking these mothers to make a choice - to choose themselves over their children, especially after losing so many years to incarceration. This proved to be an important data point. The participants who committed and attended Workshop #1 remained throughout the other requirements of the study: Workshop #2 Debrief and the one-on-one interviews. An unexpected limitation was how many potential participants and preliminary participants would be lost due to violating probation and returning to a supervised faculty, whether a county jail or a housing facility. LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 70 INTERVENTION DEVELOPMENT Intervention Introduction, Purpose & Proposal: Marians Pre-college Workshop Series Interventions are a key component of the adaptive leadership framework. This intervention was a pre-college workshop at Marian University, designed to prepare formerly incarcerated mothers to return to college, so they may feel empowered to build the capacity needed to work within the stigma and push past the stereotypes instead of attempting to change the system or flee from it. The purpose of this intervention was to provide knowledge and services to help the participant mothers build capacity within themselves and establish relationships needed to develop a comfort level in a post-secondary environment. This intervention was informed by pre-diagnostic work done for a doctorate course in Fall 2021 by interviewing formerly incarcerated mothers, as well as existing literature on barriers, programs and support services offered at other institutions of higher education across the nation. The design process, intervention itself and evaluation of the intervention relied on existing literature, communications with formerly incarcerated mothers through questionnaires and interviews, observations and communications with colleagues at Marian University, as well as professionals and staff working at other universities who offer services which support formerly incarcerated people pursuing post-secondary education. Intervention Design Overview Participants The original goal was to have fifteen formerly incarcerated mothers in Indiana, with an interest in going/returning to college, participate in the pre-college workshop series which included two workshops, each approximately one month apart, and were preceded by a LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 71 questionnaire and followed by a one-on-one interview. This goal proved to be overly ambitious; I had four participants. The plan was to choose five of the fifteen participants from an established network. Due to conflicts described previously under Limitations, three anticipated participants were lost due to probation violations; two anticipated participants never responded and were unable to be located or contacted; one anticipated participant was lost due to moving out of state; and one anticipated participant was lost due to illness. The other ten anticipated participants were to be randomly selected from responses to a callout distributed through social media outreach and organizations and non-profits in Indiana, proved to be too high a number, and conflicts were underestimated. Several factors contributed to not attaining this number of participants, including the following cited by potential participants and contacts and colleagues who communicated with potential participants (2023): Work conflict many single mothers work weekends Children with sports commitments on Saturdays (or other activities) o Faced with choosing between their self-development and being present for their children, especially after being absent from their lives during incarceration Lack of daycare Transportation/Travel o Too far to drive Commitment o Too long of a day o Too many additional requirements aside from Workshop #1 Despite my experiences teaching and volunteering in education programs with this population, I significantly underestimated how difficult it would be to get the women to come onto a college campus. While the reasons provided make sense, I am curious about what fears and anxieties may be running underneath these obstacles; there may be a lot more happening here in need of further exploration as far as alternative ways of connecting with these mothers. LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 72 The challenges that surround this population will always be there, so it may be that every workshop moving forward could be this small, even consist of multiple one-on-one workshops for those less comfortable in groups and virtual options. This may be the expectation moving forward to create various unique ways for mothers with incarceration experience to enter the college environment. Questionnaires & The Intervention Tool: The Pre-College Portfolio A Pre-College portfolio was created and provided to the participants at the beginning of Workshop #1. The intent was to provide the portfolio in advance, but receipt of questionnaires delayed advanced distribution (see Appendix A: Questionnaire for Formerly Incarcerated Mothers Pre-Intervention Workshop #1: Intervention Tool - Pre-College Portfolio). An electronic version of the portfolios resources, which also included video tutorials on online course navigation and virtual conference calling, was e-mailed to the participants, as well as university staff and faculty, on April 23, 2023. The purpose of the portfolio was to provide a tool to help formerly incarcerated mothers navigate their return to college. Decisions about the contents of the portfolio were made based on existing literature, pre-diagnostic interviews and the results of the pre-Workshop #1 questionnaires given to the participants, as well as availability of Marian faculty, staff and other volunteers available to present on various topics. It was anticipated that the content would include but would not be limited to the following: application process, college program admissions requirements, career services, counseling services, computer skills and online services, financial literacy and financial aid and grant opportunities. After the questionnaire feedback was received and the availability of the volunteers was determined, the following content was finalized: LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 73 Portfolio Binder: This was provided in Workshop #1 and included consent forms, agenda, participants bios, admissions information, online program application instructions; scholarship, financial aid and Pell information; default loans and forgiveness programs; personalized learning center resources, links and accommodations; online library services, career development toolkit packet, resume and cover letter samples and resources, and Marian University program options and student services departments Electronic Portfolio: These resources were provided via e-mail on April 23, 2023 and included an electronic version of binder contents, as well as some resources that could not be shared in the binder, such as a video tutorial on how to navigate an online learning platform for online education opportunities. The email included 10 attachments: finalized agenda, university contact sheet, admissions and financial aid PPT, financial aid and loan forgiveness info sheet, career development toolkit packet, application instructions, Marian University program options, Marian University student services, personalized learning center and accommodations PPT, and links to resources for virtual conferencing. The e-mail also contained two links to online video tutorials: one dedicated to navigating an online learning management platform, Canvas; the other dedicated to leading and participating in a virtual meeting/conference via Zoom or Webex. The portfolio served as a reference tool with the intent to benefit the participants regardless of where they choose to continue and complete their college education. The portfolio was designed to be easily shared with others. The participants may choose to share the portfolio with their peers coming out of incarceration, so they may begin to prepare for their return to college. The goal was for the knowledge gained through the portfolio content to increase the capacity of formerly incarcerated mothers. LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 74 Workshop #1 Content & Agenda This was a full day workshop, from 8:30 a.m. until 5:00 p.m. on Saturday, April 15th, on Marian Universitys main campus, at 3200 Cold Spring Road, Indianapolis, IN 46222. Participants were provided with breakfast, a catered lunch and compensated with a gas gift card and Marian University merchandise. Marian staff and faculty attended Workshop #1 as volunteers and lead sessions. They introduced themselves, their programs and/or their service areas and engaged in a Q&A with participants and other volunteers. Workshop #1 was intended to help the participants build capacity within themselves to overcome the barriers blocking their pathway to college with the hope that the participants would make progress enough to consider college despite the stigma. The morning sessions of Workshop #1 addressed technical, college-related obstacles, such as how to complete an online application, apply for default loan forgiveness and how to apply for financial aid. Other sessions explored basic internet and technology skills and library services, which included basic Google searches, logging into and navigating a basic template in Canvas as a guest user, coverage of university library services and online databases, Webex and video conferencing capabilities. While acquiring technical skills and knowledge, the hope was that this would help make progress on the adaptive challenge to increase self-esteem and build capacity to return to the college classroom, help the participants feel not so different from their peers and provide the confidence needed to overcome the stigma. The afternoon session of Workshop #1 focused on relationship, trust and capacity building among the participants and faculty and staff. A Q&A panel and small group sessions were combined due to time constraints and offered an opportunity to connect on a deeper LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 75 level and identify similarities over differences, to address fears and build college self-efficacy among participants. The following chart details the finalized agenda for Workshop #1. This changed based on the availability of faculty and staff and the needs and interests revealed by the participants in the pre-Workshop #1 questionnaires, as well as time constraints on the day of the workshop: MORNING SESSION TOPICS Breakfast, Webex set-up for one participant, Introductions & Portfolio Resource Overview DETAILS Welcome to Marian at 8:30 with the Dean of the Klipsch Educators College and the Assistant Provost and Dean of Academic Affairs. Introductions of participants and faculty/staff volunteers presented an opportunity to share narratives and lived experiences. Admissions & Financial Aid presentations Online research basics & library services overview Personalized Learning Centers presentation Learning Management - Canvas and online platforms, sample course Associate Director of Graduate and Online Admission discussed the admissions process and impact of background checks, application process, how to apply online, transcripts requests, transfer credit, individual program requirements and contact information. Assistant Director of Financial Aid discussed financial aid, how to apply for aid, how to complete the FAFSA, advances in the process, how to navigate default loans, the Fresh Start program, waiver app fee and box elimination. Director of Library Services shared online library services, system navigation, keyword searches, peer-reviewed articles, YouTube video library, interlibrary loan, and public library access and services. Assistant Director shared the departments services, medical documentation for disabilities, PTSD and pregnancy, documentation guidelines, locations for diagnosis, how to apply for accommodations who qualifies and why, legal mandates and connection to Franciscan Values. Director of Center for Teaching and Learning discussed Canvas capabilities and online platforms and presented a college course walk-through. LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS LUNCH TIME SESSION Over Lunch Career services, degree pathways, job outlook Due to time constraints, video tutorials on Canvas were provided to the participants via e-mail, as well as video tutorial on the navigation of virtual conferencing tools, Webex and Zoom. DETAILS Lunch catered from Cholita Taqueria Lunch time guests presented on career services and local programs and resources for justice involved students. Marian alum from Recycle Force, in Indianapolis, Marion County, discussed the role of Recycle Force, job placement, job advancement, and their role in community. Portfolio and electronic portfolio included a Career Development Toolkit out of the Exchange at Marian University, as well as resume and cover letter resources and samples. AFTERNOON SESSION TOPICS Debrief & Reflection: capacity, voice, vulnerability, boundaries, empathy, fears, language, word choice, and next steps DETAILS Researcher kicked off the session; a participant shared her narrative about her college experiences in Florida. Participants Q&A helped guide conversations. Q&A and group discussion session with participants and university staff and faculty Marian faculty or staff representatives were invited from several colleges and departments to discuss their programs, classroom spaces, views on justice involved individuals on campus, experiences teaching in a prison, etc. Wrap-up & Next Steps How do we continue the work? The morning sessions inspired more discussion and questions than anticipated, so due to delayed lunch and afternoon time constraints, the Q&A Panel and the Small Group Session were combined. Three of the participants, as well as several of the Marian faculty, want to continue the work beyond the research and capstone. A committee has formed to begin work in July 2023 with a focus on grants and the formation of a mentoring program for mothers with incarceration experience and justice involvement. 76 LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 77 Workshop #2: Debrief of Workshop #1 Workshop #2 was conducted virtually and recorded via Webex on Saturday, April 29, 2023 and was a debrief on how the participants experienced Workshop #1; this included the researcher and all four participants. This provided participants an opportunity to provide feedback on their experiences - in a group setting - on what went well and what could have gone better, what should be kept, added or removed if this workshop were to be offered annually. Knowledge gained from Workshop #2 and follow-up individual interviews with participants helped to identify strengths and areas in need of enhancement for the next pre-college workshop series, as well as identify what changes may need to be made to the intervention tool. There was open discussion about the intervention tool, the Pre-college Portfolio, and how they experienced Workshop #1. The following questions were used to help guide discussions in Workshop #2: Please describe your experience in Workshop #1. What did you enjoy? What did you find challenging? What assumptions did you have going into Workshop #1? What was confirmed? What shocked you? What relieved you? What fears did you have going into Workshop #1? What fears have been lessened because of Workshop #1? As a result of the Pre-college Portfolio tool? How do you feel you showed up in Workshop #1? What about the faculty and staff how did they show up and how did they make you feel? What did you notice about your own body language? What about the body language of the other participants? What about the faculty, staff and guest speakers? What about Workshop #1 would you recommend be kept for next time? Why? What about Workshop #1 would you recommend be eliminated for next time? Why? What do you think should be added to the Workshop and how do you think that addition would be helpful to students? Would you recommend the Pre-college Workshop Series to others? Why or why not? Have you referred to the portfolio since Workshop #1? Have you shared the portfolio with anyone, or do you intend to share it with anyone? Is the portfolio a tool that helped you overcome the stigmas you have faced? What do you view as the next step for colleges on how to help you? LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 78 One-on-One Participant Interviews An anticipated concern was how comfortable the participants would feel about providing feedback in a virtual space with the group; therefore, each participant was also interviewed individually via Webex. Each interview was recorded and transcribed. Summary of Intervention Steps & Timeline Intervention Timeline Pre-Workshop #1 questionnaire to the participants about the intervention tool: the Pre-College Portfolio Workshop #1 on Marian Universitys main campus After IRB approval January 2023 April 2023 April 15, 2023 Workshop #2 Group Debrief via Webex April 29, 2023 Follow-up individual interviews of participants May 9th (Angela) May 12th (Lisa) May 16th (Zaynab) June 1st (Ashton) LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 79 INTERVENTION EVALUATION & FINDINGS The purpose of this study was to make sense of the formerly incarcerated mothers lived experiences and uncover causes of the participants challenges in returning to college. Another goal was to identify services and support that may be helpful for them to make progress on facing perceived stigma which may have hindered their movement and how they have experienced education with a criminal history and how that has impacted self-efficacy. The phenomenological researcher cares more about the essence of the [lived] experience (2015, p. 252), which is why the results section of the study is heavily dependent on many raw, direct quotes from the participant mothers in an attempt to recognize what is at the heart and core of those experiences, as opposed to relying on the researchers interpretations. Continuous recognition is given to the womens advice on how to improve the workshops and portfolio, which embraces the phenomenological approach. For the sake of this study, the focus was on external re-entry obstacles related to college, such as affordability, accessibility, admissions setbacks, the burden of parole and probation, defaulted student loans, and navigation of advanced technology. These external obstacles contribute to anxiety and distract formerly incarcerated mothers from taking those first vital steps toward college. While these obstacles are important to understand and address because they contribute to emotional capacity, the core of this study turns to the participants internal barriers of stigmatization and self-efficacy. How does fear of judgment, anxiety and low self-esteem deter formerly incarcerated and justice involved mothers from a post-secondary education? How do external obstacles impact internal barriers, and how would the lessening of external obstacles lighten internal barriers? Which services and programs can be put in place to help these mothers find ways to LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 80 make progress within themselves and build their own capacity to excel through the stigma and increase college self-efficacy? Data was collected and analyzed from the group debrief and the individual participant interviews, as well as the detailed Workshop #1 observations of a non-participant and my notes from Workshop #1. This data permits an understanding of the mothers lived experiences and helps determine if the intervention had an impact on their emotional capacity, college selfefficacy and self-esteem. The data may also suggest the likelihood of this intervention having an impact on others with incarceration experience and/or justice involvement on their paths to college. Analyzing and synthesizing the data, the interventions revealed the following themes and subthemes: THEMES Internal Barriers to Freedom External Obstacles to College: Roles of the Institution EXTERNAL SUBTHEMES INTERNAL SUBTHEMES Faculty, Staff & the Administration College Self-Efficacy & Self Esteem Growth, Progress & Adapting to Change INTERVENTION SUBTHEMES Navigating College & Stigma: Portfolio Tool Feedback Admissions Building Capacity & Belonging Experiencing the Workshop: Enhancements for the Future Library & Technology In F#@k It, there is Freedom!! Where are you in your journey? Conquering Triggers & Overcoming Stigma Emotions & Energy Employment Services & Career Pathways Organization Design: Virtual Participation & Length Technology Enhancements The Against Viewpoint Future Research & Continuing the Work Degree Options, Career Pathways & Partnerships Mentoring Programs LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS Career Services Fear & Vulnerability 81 Financial Obstacles Committee Formation Social Media & Advertising Capstone Summary External Obstacles to College: Roles of the Institution Universities present obstacles, some of which they may not be aware, that scare away formerly incarcerated students before they have a chance to enter the classroom (Bumgardner et al., 2019). They have little access to support before they even begin the application and enrollment process they have little connection to college campuses and lack feelings of familiarity and a sense of belonging (Bumgardner et al., 2019, p. 65). A goal of this intervention was to offer knowledge, support and guidance along the mothers pathways to college. This intervention created a safe, welcoming space for the formerly incarcerated mother participants in Workshop #1 on April 15, 2023 to ask questions and share their stories and lived experiences surrounding their attempts to return to college. The morning sessions focused on external obstacles in hopes that knowledge and support would increase college self-efficacy and self-esteem and offer a sense of belonging. Faculty, Staff & the Administration At the April 15, 2023 Workshop #1, the universitys Assistant Provost & Dean of Academic Affairs welcomed the group and thanked everyone for coming. He shared the goal - to provide guidance in enrollment into higher education, learn more about obstacles, the experiences of the participants, and how to navigate through the participants journey for higher education. He said, we will learn from you as much as you from us and that we realize many policies and procedures contribute to your obstacles some are not things we can changewe want to see what we can all learn from each other. (Julie, personal observation, 2023, Apr.15). LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 82 This set the stage and created a welcoming atmosphere immediately. This was the objective of the day to learn, communicate, discuss and make progress where we can, such as looking into which colleges and programs at the university may still require a background check and if there is any way to remove it (personal communication, 2023, Apr. 15). University faculty, staff and administrators are critical to student success, and when students perceive faculty attitudes to be negative, disrespectful or non-welcoming, it impacts their motivation and confidence level (Binnall et al., 2021). In the group debrief, participant, Lisa was blown away by the response that we hadthe way that everybody was working together from Marian to try to improve things honestly didn't think that it would be such a great reception. So that I was absolutely just blown away with. (personal communication, April 29, 2023). Angela echoed Lisas sentiment, it was nice to really hear faculty at a university be so supportivethe time that we spent after talking, you know, like we really like there was, there was a lot of energy with it. (personal communication, April 29, 2023). Ashton also appreciated how everyone came togetherwilling to hear the voices of, and the challenges that everyone faces (Ashton, personal communication, June 1, 2023). Ashton faced some personal life conflicts the morning of the workshop and joined via Webex and shared how that impacted her morning (personal communication, June 1, 2023): They made me feel like I was there and a part of things, although I was on the other side of town, and at a service, and doing other things, so they just made me feel like I was a part of things, cause everybody does not work well under pressure. You know, nobody knew that I wouldn't be able to make it, even myself, so I think that the staff kind of handled my situation accordingly, and I, I really appreciated that. It made things happen so I could participate, and I even still received everything that everyone else received, besides like having lunch with you guys, like that was the only thing that was the difference. (Ashton, personal communication, June 1, 2023) In Angelas individual interview, she spoke to the body language of the staff that they LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 83 had really good body language, like just very open body languageand as far as the faculty went was, was amazing (personal communication, May 9, 2023). Lisa remembered back about body language the day of the workshop, and shared that no matter how professional they are in their career, or in their place in that space, it was a casual, even-keeled type of thing. Like nobody came across better than anybody else. I don't think you know, like it seemed that everybody was open and receptive (personal communication, May 12, 2023). Lisa felt like the staff showed up as one of us (personal communication, April 29, 2023). Even though they may not have been able to relate, they were actually listening, you know, so I felt the open mindedness, and the acceptance made me feel probably more human that Id felt in other places besides my home in a long time (Lisa, personal communication, April, 29 2023). According to Ott & McTier, faculty members are critical socializing agents (2020, p. 298) who impact whether students can integrate into their college environments and stay through to graduation. The support the participants felt from university faculty and administrators is crucial in helping formerly incarcerated students feel welcome on campus and combat the stigma (Murillo, 2021). Admissions In the debrief, Zaynab spoke to her experience with admissions at other schools, how much damage it did to her capacity and how it impacted how she showed up at the beginning of Workshop #1 (personal communication, April 29, 2023): to be honest with myself, it was like for me, it was I, I went into [it] like a daze because when we got to talking about the admissions part, I got the, I start remembering my admissions when I went through the challenges that I was facing when I had previous involvement with the criminal justice system, and it was like I remember having to - after going through admissions and being enrolled in two to three weeks, I had to get dropped from my classes because of my background. So really through, like through that process it was like a lot of memories from my past just kept popping up, and it was just like and it, and it kind of blocked me from trying to hear like the progress of what theyre willing to do, the progress to, to kind of help the situation as far as moving forward, when I was still kind of dealing with my own trauma from my past. That still kind of hinders LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 84 me as far as moving forward to, you know, through the admissions part, to get myself enrolled because I keep thinking about my past a lot. And it's been something that's been hindering me for years. (Zaynab, personal communication, April 29, 2023) Zaynabs description of feeling blocked by her trauma relates to Albert Banduras selfefficacy theory trauma victims were found to have lower self-efficacy levels (Heath, 2009; Bandura, 1977) keeping them from moving forward. Expanding self-efficacy is an intervention that could increase the emotional capacity of a trauma survivor and reduce the stress they feel in a given environment or circumstance and increase ones perceived ability to cope with and manage a given stressor or anxiety. Ashton offered a great recommendation related to the admissions process by describing assistance with the application process to ease anxiety and eliminate an obstacle something universities can do and also something that may be added to the Workshop #1 experience moving forward (personal communication, June 1, 2023): I really want to go back to school. I feel like we should have like an application process. Like, Hey, are you interested in signing up for classes? If you are, you can start with these documents right here.you don't have to finish it today, but here's the starting process because it might give somebody a boost. That might give them the push that they need. Like, Okay, it's right here in my face, I might as well do it, and get it over with. Because I wanna go to school so bad, and I just keep jumping up every time I get on the computer I jump up, I have something else to do, and like in the training you have, you have [somewhere] else to go. Like you're sitting there, so you, so you should be able to do it right now. This is an excellent recommendation to sit down and walk potential students through the online admissions process - and could be something arranged for students who make the decision to attend the university. Library Services & Technology It is impossible to survive college without at least a basic level knowledge of technology. The authors of Spotlight on Indiana: Barriers to higher education for incarcerated and formerly LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 85 incarcerated students warns, if you don't have that knowledge, you're handicapping somebody almost to the point of incapacitation They cannot function not knowing how these things work and how the world works now... (Bumgardner et al., 2019, p. 80). Not knowing how things work can be an insurmountable obstacle, especially if just asking for help causes anxiety. Lisa shared that it felt good to know she was not alone in not knowing how to do certain things (personal communication, April 29, 2023): just to hear the stories, like to know that you don't have to be incarcerated for so long or, you know, be a recovering addict to not understand how to use a library, or to not know how to do, you know, certain thingsto hear it from somebody in positions that everybody was in made me feel just a little bit better about having to ask questions; not so inadequate. And that was, um, just an example like the librarian looking things up, but there were many things. (Lisa, personal communication, August 29, 2023) Lisa asked the librarian about how to find specific sources online and how to determine which articles are peer reviewed (personal communication, April 15, 2023). While incarcerated if in an education program others do the research on behalf of the students, so when the students are released and pursue college post-incarceration they get out and have no idea (Lisa, personal communication, April 15, 2023). The librarian communicated that she would be open to recommendations on how to make the online library website easier to navigate many strides have been made over the years, but they are open to consistent improvement (personal communication, April 15, 2023). They are organizing a student driven focus group to provide feedback to the university library to which Lisa will be invited to participate (e-mail communication, April 15, 2023). This was a great example of how we can make small, but significant progress. Career Services A representative from career services at the university was unable to attend the workshop but provided a career services toolkit to include in the portfolio. Lunch time guests presented on LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 86 career services and local programs and resources for justice involved students. A Marian alumna from Recycle Force, in Indianapolis, Marion County, discussed the role of Recycle Force, job placement, job advancement, and their role in the community. One participant was able to connect in hopes of launching a partnership between Recycle Force and her place of employment; however, the career services discussed on April 15, 2023 were focused on Marion County residents. As Lisa pointed out, options are extremely limited for anyone living in other Indiana counties (personal communication, May 12). Lisa referred to an employee in career services, her advisor and the financial aid representative as being her life savers (personal communication, May 12, 2023), but career services was noted as an area in need of enhanced representation in future workshops (Lisa, personal communication, May 12, 2023): I think resumes are very important, and it was touched on. Maybe even take time to do like a practice one or somethingwe didn't break up into little groups or whatever, but I think that if the next one that was, that there was timing available for that then, or even if not, we could do like a mock interview, maybe that way somebody could see how to answer the questions, and what kind of questions are going to be asked? Because even to this day, I have so much trouble trying to answer questions about the gap of employment. Other people come straight out and just tell them, like I worked for the State of Indiana. Well, to me, I feel like that's dishonest because I didnt work for the State of Indiana, I was forced to, you know, so how I, I just don't. I'm uncomfortable answering those types of questions still. (Lisa, personal communication, May 12, 2023) What Lisa mentions about working for the State of Indiana is in reference to jobs the mothers had during their incarceration, whether it was a clerk for one of the programs, a cook or working in the daycare in the baby dorm, they all had jobs. Explaining gaps in resumes due to incarceration is an area of discomfort, as well as identifying degree and career paths. Lisa shared her struggles with finding a career path. She does not want to be a counselor or work with addictions and feels she has been shoved into that box, as if that is her only option because of her criminal history, cause I'm gonna tell you it took me months to be okay with that LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 87 because I felt like I was not only failing me, I was failing other people, because I, I feel like this (Lisa, personal communication, May 12, 2023). I'm not gonna, I don't say, singled out in a negative manner, but I kind of was singled out in the fact that I'm kind of the only one that hasn't followed my path on helping people on a daily basis, you know, that have struggled with the same struggles that I've struggled? Like I like doing this, giving my testimony helping kind of I guess you would say behind the scenes, you know? I don't want to work with, like, addicts on a daily basis, or people in the justice system. I, I honestly thought I did until I came home and did it, so I feel like having different perspectives like that was probably more of a benefit that you didn't know was going to be a benefit, you know? I think that maybe that's something that you could shoot formthe next time is not having everybody that on the same path, you know, cause like Angela has her path, and Zaynab has her path, and ones in the criminal justice ones in, you know, recovery and helping, and all that, and then here I am like Hey, I'm working in a factory because I don't want to deal with those people. You know like Ill help em from here, but it's just as much as I honestly thought it was my calling to do it every single day, I feel like I could probably be more harm to either them or myself, if that was me. Maybe I'll find a position, unlike the ones that I've tried, because the ones I've tried just haven't been for me, and so that might be something that could be pointed out was like just because you think that this is your path, and this is your passion, it doesn't have to be, and it's okay for it to change. (Lisa, personal communication, May 12, 2023) Finding more career pathways is an important next step for organizations to help women like Lisa who are not certain of their options and what may be a good fit. I'm struggling a lot with career path because I don't know. I just don't know what I want to do. (Lisa, personal communication, May 12, 2023). According to Murillo (2021), this is a common challenge, and there is a direct connection between employment and college. Students straddle two employment problems: finding work and juggling work and school (Murillo, 2021, p. 14). Colleges need more targeted student support for degree selection and career options. Advisors lack knowledge on career pathways for formerly incarcerated students, and there are limited and inconsistent services, leaving formerly incarcerated students as their only advocates. (Murillo, 2021) LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 88 Internal Barriers to Freedom Zaynab loved the information on admissions, financial aid, etc., but especially appreciated the afternoon session on how to help individuals transition mentally, physically, emotionally, and to give them the mental health that they need to keep moving after transitioning it into the world really (personal communication, 2023). Zaynab shared that in the beginning of the workshop, she felt motivated by some of the university staff to return to school but is still dealing with trauma and it's not so much of the facility or the event, or anything like that, it's just the traumashaving to deal with so many doors being closed, or the rejections, or not being able to sustain housing, or affordable jobs or, you know, just having things like that blocking me from moving forward (personal communication, May 16, 2023). She wants to learn how to really use my lived experiences for the next individuals that need help growing (personal communication, May 16, 2023). These womens needs far exceed simply getting into class (Case, 2005, p. 150). Their biggest self-identified barrier was low self-esteem. Self-esteem, selfimage and psychological obstacles intersect the external obstacles and are just as important to address (Case et al., 2005). Obstacles within ourselves are powerful (Angela, personal communication, April 15, 2023). College Self-Efficacy & Self-Esteem While the literature reveals numerous structural and social barriers unique to women and mothers, the most significant roadblock to pursuing college is their own struggle to believe in themselves and view themselves as college material (Bell, 2020, p. 7). Lisa shared about her journey to campus the morning of April 15th. The drive alone was a barrier and created anxiety traveling to the workshop. She drove three hours, and it was the first time she had driven that LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 89 distance alone. She was encouraged by the fact that she was traveling to her school where she felt grounded. (personal communication, April 15, 2023) Lisa shared her surprise about experiencing such an immediate breakthrough that Saturday (personal communication, May 12, 2023): I knew that what the topic was going to be and that it would be received somewhat in a positive manner, but I also had assumed that there wouldn't really be a whole lot of breakthrough immediately, that it was more or less going to be [about] what can be done in the future and by future, I'm used to years, you know, like within a couple of years this can happen I didn't have any negative assumptions except for my nervousness, and I had assumed that at least one person would look at me like I felt - a weirdo, you know? What shocked me was the reception that we had, the understanding, and the wanting to understand. The wanting to know more and the compassion, it blew me away. I did not feel weird at all. I actually opened up more than what I thought I would be able to and the immediate response, and action that was taken by a lot of the Marian staff absolutely shocked me. So I was relieved that I could say how I felt(Lisa, personal communication, May 12, 2023) Compassion and empathy were in the forefront of the entire workshop but especially in the afternoon session, which seemed to be the participants favorite part of the day. This is what may have impacted capacity and self-esteem the most. Zaynab spoke to the afternoon portion of the workshop in the group debrief and how she felt when we really engaged as a group and reflected on the day (personal communication, April 29, 2023). She shared that it was an amazing experience (Zaynab, personal communication, April 29, 2023): how everyone just came together, we kind of just, just even sat in the light, the, the dark for a little bit turned the light off, and we all just kind of breathed for a second. You know, I think that shouldve been towards like the front just for everybody to [decompress], and I think, it was like towards the end when everyone really started speaking about the issue that we were there for in a way, and I felt like that should have been the main topic. (Zaynab, personal communication, April 29, 2023) The afternoon session seemed to have special meaning to her because Zaynab addressed this again in her individual interview - how much she enjoyed that space to reflect and breath (personal communication, May 16, 2023). We paused life, uh, and everybody just reflectedit LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 90 was like all my anxiety and everything that I had on my chest lifted like butterflies and just lifted me, and it was just like, I love this. This is where I, this is where I could really talk and be myself. (Zaynab, personal communication, May 16, 2023) Even though Ashton joined the session on Webex, she expressed similar feelings as Zaynab about the afternoon session: one of my favorite parts of the event was towards like, the endwe all got to kind of relax, just take a breather, and just like really go into details of about everyone's kind of background, and to really understand why the support is there, and where the support come from? (Ashton, personal communication, 2023) Building Capacity & Belonging You are not the product of your circumstances. You are a composite of all the things you believe, and all the places you believe you can go. Your past does not define you. You can step out of your history, and create a new day for yourself. Oprah The participants were welcomed to Workshop #1 with Oprahs quote delivered by the Dean of the Educators College, then followed by introductions (personal communication, April 15, 2023). A common theme among the participants introductions was that they had a passion to give back, be a better person, to help people, to be included, to get to the top, and to get their education (Julie, personal observation, April 15, 2023). Did the intervention the workshop and portfolio tool - build capacity? According to the participants, it did. Lisa shared that she felt like my feelings were validated in that workshop (personal communication, May 12, 2023). On building capacity, Lisa explained what the workshop did for her (personal communication, May 12, 2023): So some of the fears that were lessened was, I'm not gonna say I'm completely quote, unquote, healed from asking the questions, but like in my class right now, my capstone class, we have to do a recorded response, and I can't figure out the app, and instead of spending days on it trying to figure it out because I didn't want to feel inadequate or less than or weird or whatever, within an hour or so I already emailed the instructor and was like, listen, Uh, can you give me some instructions where to find this at? Because I LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 91 guess the workshop gave me a little bit more confidence, what on whether I know it, or not, the people that are teaching me, the people that are involved in this higher education program, care enough to understand to help. You know? They don't look at it as an excuse because that's I guess, being an addict my whole life, I made excuses for everything, and so I'm very hesitant to say, I don't understand this, or whatever because in my mind, it's an excuse, but nobody takes it as that, and that is a huge relief, and a fear that is way lessened. (Lisa, personal communication, May 12, 2023) Building capacity is often accomplished outside of ones comfort zone. Lisa spoke about everyone showing up in spaces with an agenda, and she elaborated on that here, as she spoke to her own agenda coming into the workshop and her own comfort levels (personal communication, May 12, 2023): I guess, you know, when I talked about how like I had, I had my agenda, and I felt like everybody like had theirs, like in this tunnel vision type agenda, it was like me to help people in the future not go through the same things that I'm going through. The library was there to helpfinancial aid was therebut every single person like overstepped their own comfort zone, their own boundaries and, you know, had advice, or help, or offered something in every other department, and I walked away with way more than what I thought I would walk away with that would help me presently. You know? I felt like my agenda was there to help others in the future and thats I, I really didn't know how it would help me in today's, you know, in, in my life today, but it did way more than what I thought it would. (Lisa, personal communication, May 12, 2023) When asked about building capacity to face the stigma, Ashton shared that she felt welcome before entering the workshop space (personal communication, June 1, 2023): I automatically knew like this was for people that have backgrounds, and that will be accepted. When it's, when it was explained to me, I'm like, Okay, so I'm assuming they accept backgrounds, and once I got to looking at the flyer and stuff like that, the flyer was like, Okay, bam! They absolutely take people with backgrounds, look at the flyer. It was just like it was real. It was raw so it didn't, it didn't scream to me, You're going to be denied because. certain decisions that you've made previously, they're not going to be held against you. (Ashton, personal communication, June 1, 2023) Many women were some type of victim and are filled with toxic trauma before they entered the justice system (Lisa, personal communication, May 12, 2023). There is self-blame associated with that. Based on Julies observation notes (personal observation, Apr. 15, 2023), the participants were thankful for spaces to be when unsure about resolutions/answers and LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 92 thankful for the open conversation, thankful for everyones time they felt valued, especially someone from the outside coming inside to help us (Lisa, personal communication, April 15, 2023). It gives us hope (Angela, personal communication, April 15, 2023). Angela shared how important safe, welcoming spaces are to this population (personal communication, May 9, 2023): having that space where people who feel like they don't belong feel acceptedI think that could be a very important space to build that belonging to bridge some of that internal struggle about not wanting to go, to make effort to go back to school or to, to apply, um, because you're scared. What are people going to think, you know, this and that? To be able to sit and feel like you belong in that, you know, like I mean, we even did that the circle and, and to feel like you're part; that could be powerful. (Angela, personal communication, May 9, 2023) Feeling a sense of belonging is critical, and the afternoon session was about building capacity in an open space. Angela shared her story with the group that afternoon how she worked so hard years ago to hide her incarceration history with fellow students and faculty when she was in college in Florida. Her mentality was if Im perfect, no one will ask questions, and I can blend (Angela, personal communication, April 15, 2023). Since then, Angela is expanding her wings and wants to be in spaces where she can talk freely about her past youre going to accept me, or I dont want to be there (personal communication, April 15, 2023). But it takes time and work to get there, and the participants were all in different places in their lives. Zaynab shared that she still experiences moments where I feel like I'm secluded from the group or I feel like someone is still thinking about my past, or might use my past against me, and then, sometimes, when I'm in these organizations and I'm sitting at the table, I ask myself like, why am I here, or how did I get here? Like, Am I really acceptedit's just the thoughts of just my past just constantly hindering me (Zaynab, personal communication, April 29, 2023). Angela wondered if Zaynab may have felt a little scared when she first walked in the LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 93 room on Saturday, April 15th or had some anxiety (personal communication, May 9, 2023); Ashton also noticed that some of the participants appeared a little tensebut the people that were kind of tense got to tell their story, you know, and kind of got emotional, and then that body language changed, and they were comfortable because they felt like they weren't judged (Ashton, personal communication, June 1, 2023). Speaking to Zaynabs perceived anxiety, Angela noted, I think that she came out of that (Angela, personal communication, May 9, 2023). Zaynab confirmed Angelas observations (Zaynab. personal communication, May 16, 2023): At the beginning of the event, I was nervous. I was nervous because I still had those thoughts of like, Am I supposed to be here? And that's all I kept thinking aboutgoing back and forth with myself because I was sitting there like, Zay smile. Like, Zay, speak, its okaybut then it was like towards the end when I got to be around more individuals, and we actually spoke on the, like what we were there for, and everybody start, you know, introduce yourself where they come from. What they've done. It was like that moment it was like felt really welcomed. Oh my gosh, like I was opening up more, and it was like, Zay, you should have been doing this from the beginningYou don't have those hindering you anymore. Its okay to be where you at. Its okay to speak (Zaynab. personal communication, May 16, 2023) Angela was right; Zaynab came out of it. From this short time together, I could feel a sense of community, and closeness with this group. Individuals were genuine, and heartfelt sharing. (Julie, personal observation, April 15, 2023). The day began with Lisas introduction about her emotional three-hour drive to campus and ended with her goodbyes to the group. She thanked everyone and said she found this to be helpful. Maybe I am further along that what I thought (Lisa, personal communication, April 15, 2023). In F#%K IT, there is Freedom!!! Progress was not for just me but for my kids, God, family, finances, school. Everything I do is for my children. (Zaynab, personal communication, April, 15, 2023) Single mothers are often primary care givers to their children, which brings a unique set of barriers; motherhood creates more obstacles upon re-entry (Mitchell & Davis, 2019). In some LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 94 pre-diagnostic work in October 2021, K.B. explained that coming out of incarceration, there is always that pressureI cannot dare miss a soccer gameeven if I justify it in my own head, then I feel the guilt and the shame when I am around other people (personal communication, 2021). Mothers face gender bias because they have not or do not sacrifice themselves completely for their children. This issue presented itself in the research process pertaining to attendance at the all-day Saturday workshop. Several participants were faced with choosing themselves by attending an all-day Saturday workshop for college or attending their childs soccer game or other sporting event or activity. One of the participants shared the following regarding the conflicts faced by several potential participants who had to decline participation, when asked if conflicts with children limited available participants (Angela, personal communication, May 9, 2023): And that, and that I know for a fact. I've had people tell me that they couldn't come that had planned on coming because of whatever One had a basketball, was it basketball, soccer game; one had a soccer game. A friend of another friend of mine couldn't come because her son is in a, he's in a, like a treatment facility of some sort; A behavior health facility, and so like she had to Saturdays, is the only day she can visit. So a half day she could have done a half. She couldn't but, she, she either had to be there in the afternoon or in the morning. So I later found out that Zaynab missed her sons soccer game that Workshop Saturday, April 15th. That is part of being a mom; it comes with tough choices. Zaynab explains that while she is sitting in events at various organizations (personal communication, April 29, 2023): I think about the kids, and I think about all the efforts, and the, the contribution that I have to do, and sometimes I feel like I have to go harder because of my past. So sometimes it's like I'm having to do extra. I feel like I need to do extra or save more just to feel like I'm a part of it, and, and sometimes I have to kind of tell myself, like, you know, just breathe, step back, you know, it's okay. Like, You deserve this. (Zaynab, personal communication, April 29, 2023) That was a core message you deserve this - delivered by faculty in the afternoon session of the workshop. One of the university faculty members, who is a single mom, shared a quote LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 95 from her son, who is a college student (personal communication, April 15, 2023): In, f#@k it, there is freedom!!! Often held back by the anxiety of not fitting in or being judged or failing, he realized that he needed to release all those fears, or he would never make progress within himself. He needed to believe that he could do it and that he deserved it. This story impacted everyone in the room on Saturday, April 15th, and the women nodded, laughed and shouted out in enthusiastic agreement (personal observations, April 15, 2023). Zaynab mentioned that she is trying to be there for her children and for others but not forget about herself and to remember the importance of self-care (personal communication, April 15, 2023). Being a mother while re-entering society was hard due to not being able to provide for my children. Such as obtaining a good paying job to be able to afford housing and to access Higher Education. It impacted my return to college hard because I couldnt get the credentials that I needed to access other things. (Zaynab, questionnaire personal communication, 2023). When asked how her role as a mother impacted her re-entry and return to college, Lisas response looks a little different, as she is mother to four grown daughters (questionnaire response/personal communication, April, 2023): Returning home was scary enough knowing that I had to find a place in my childrens lives because for the last 12 1/2 years, they developed a routine and a life and the only part I had in it was on the phone or monthly visits. I had to build relationships and get to know each and every one of them on a daily basis as they had to get to know me actually, I had to get to know myself in the free world because life is way different than it is in a secluded prison environment. (Lisa, questionnaire response/personal communication, April, 2023): Mothers carry so many responsibilities how realistic is it for them to be able to show up inperson in so many physical spaces? This creates even more barriers, and because of the depth of these challenges, this truly is an under-represented population, especially single mothers with younger children in the home they face more challenges with daycare and activities than LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 96 mothers with grown children living on their own. Angela shared that it is easier for her to return to school my kids are grown (personal communication, May 9, 2023). Unlike incarcerated fathers, many of these women are single mothers solely responsible for their children (Equal Justice, 2020). One of the faculty volunteers recommended offering daycare during the workshop and was curious if this would have attracted more participants. It is tough to say for certain was it lack of daycare or childrens sports and activities. When asked if this workshop and portfolio content was/is specifically helpful for formerly incarcerated mothers to gain some capacity and gain some knowledge to hopefully make some progress in a small way, or to gain some confidence in a small way, and overcome some of the stigma attached, Lisa shared (personal communication, May 12, 2023): I dontThere is some focus on mothers in it, um, but it's more for, I would say it, it ended up, and I don't even think it's so much as women as maybe post incarceration, but also underdeveloped type of people, people that have chosen the wrong path maybe that didn't get caught and go to prison, but want to change their life, can still use this because to be honest while I was in my addiction, I didn't spend time learning what was being taught, um, like technology wise or or anything like that. I was busy committing crimes I'm going to use my daughter as an example. Um, she's been in and out of jail, but most of the things she knows how to do on the computer are illegal. You know?... So this binder and, and this type of workshop is important to people like that She doesn't have the incarceration to use as a reasoning, so by having something like this, it might help people in her situation, um, take that initial step to do something because then they don't have to feel that vulnerability, or the embarrassment of saying, excuse my language, I'm just a screw up, you know, I don't, I dont know it because I'm, I'm a screw up. But you don't know that cause you didn't see me in the paper. You know, um, it's easier to admit something when people already know So even if it wasn't for mothers, I feel like, just like Saturday, how it turned out is supposed to be how it turned out, and I feel like it turned out the way that it was supposed to be turned out because what if it was just for mothers that were incarcerated? And say there's only ten of them that you know of right now, but there's fifty people that wanna go to school that are scared to admit their past, and all they have to do is, Hey, here's check this out, because I've talked to my daughter about it, you know? she's coming over next week and we're gonna go through some of that because I'm trying to get her to go to school. You know? So, something that you created actually for two of my daughtersSo this binderis going to help two of my kids, you know? (Lisa, personal communication, May 12, 2023) LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 97 Lisa makes powerful points here. There is a significant population overcome by addiction and other challenges, who were just never caught and arrested, who may be able to benefit from this information, return to college and find new pathways that may never end up leading to incarceration Zaynab - coming into the workshop assumed there would be more focus and discussion of women with children and elaborated below (personal communication, May 16, 2023): I have to say, going into it, I expected more of, more talk about the women with children. When we went there, I felt like it was more so of like an orientation to college, which is still okay because there was an introduction by education too with women with children, but I just, I wanted to hear more as far as what are we going to do for these individuals? What programs do we have involved? Who are we connected to? What do we need to do? You know, just, I guess kind of going from there. Being in this space, especially towards the end of the event really was amazing for me. We got to actually sit and kind of talk more. We got, we expressed like our views and our opinions, or kind of even our own stories from how we kind of relate or just support in the women with children in the situation as far as being incarcerated, and that part to me was the most beautiful moment of the whole event. (Zaynab, (personal communication, May 16, 2023) This is strong feedback from Zaynab and stimulates new ideas for future workshops. As for programs and partnership, which is my interpretation of part of Zaynabs feedback, that is outside the scope of this study but is part of desired future research and progress. Fear & Vulnerability Formerly incarcerated students fears are legitimate: campus stakeholders often harbor prejudices about students with an incarceration history (Binnall et al., 2021; Copenhaver et al., 2007; Ott & McTier Jr., 2020). Angela was surprised byhow genuinely nice the staff was and how openly accepting they were (personal communication, May 9, 2023). Her biggest fear was not knowing what would be expected of her in the workshop space, but the day flowed well; she realized her fears were unfounded. She further explained that her initial fears were taken away LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 98 as the day went on and, and, and just feeling so welcomed, like it just, and like my voice mattered (Angela, personal communication, May 9, 2023). Zaynabs expression of her fears goes back to those feelings of not belonging and not feeling deserving, as she shares how she experienced the beginning of the workshop (personal communication, May 16, 2023): My fear going into the event was flashbacks of my own trauma of just having that guilt of am I supposed to be here? Am I underqualified or you know to even be around these great leaders or, you know, this event? It was just like. Felt like everyone's there has, you know, got to a point in life to where, like they probably didn't even experience a lot of things that, you know, some of us that were there went through, so to me, it was like sitting next to the great leader, or you know, the, the Dean, or stuff like that and it was just like, I, it was an honor to be sitting there, but it was fearful, because it was like, I had resentment of like, I'm not supposed to be herethen when they talked about college, I started thinking about all my flashbacks of being turned away from college ... It was really hard because I haven't even really attempted to follow through as far as going back to school because I remember just signing up for school. Going through the admissions. Going through the financial part. Sitting on my classes. Being in class for like two to three weeks, and then advisor come and gets me out of the class, and tells me, Oh, because this is on my background, I have to withdraw from the program because I wouldn't be able to get a job, or, you know, go anywhere after the thing, and in my head I'm thinking, Well okay, well I understand I might not be able to do the job, but I can I still go through with the program because it keeps me on track and, and it puts me in a situation to where I don't have to fall back to society, and I wanted to get away from, and they still just turned me away it was really welcoming and that meant a lot to me because I've always had doors closed on me. (Zaynab, personal communication, May 16, 2023) The fears did not seem to impact Zaynabs confidence showing up in the space which was intriguing. When asked about how she felt she showed up and how she thought others showed up, she said (personal communication, May 16, 2023): Well, I remember as I pulled up First, I have my t-shirt, Felonies do not Define the Future (Laughing.) So I did have that shirt on, so when walking into there I was already prepared to represent the new and approved me, the successful Zaynab. The one that went through PACE. The one that went through different types of organizations for training. The one that met Mr. Mears who got a job offer on the first day of meeting him. Who, working at the Prosecutor's Office now, to now being invited to great events like Marian University. So walking into there, I was walking in with the different headspace of like, This is, this is me! This is what I've been waiting for! Like I was really LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 99 excited, and when I walked in, like I said, it felt like, it felt like the sun, like God was just over, just like, You're here!!! Like it was. really amazing! I, I was serious like when I walked in the room, the event was well put together. I mean, from how you had it set up from the appetizers, to just the portfolio of the book, and how everything was labeled out, I loved it! Like I really felt like I was on a new level in life that I didn't think I would ever get to. The faculty members they were also kind. They were sweet. They listenedThey sat there and, you know, they gave us time to speak. They also was understanding, and it was, it was great. Like, like I said, I didn't even Like I remember applying for the Saint Joe program, like last year around November, but it was like actually being there at that event. They made me feel like I was already attending school (laughing.) (Zaynab, personal communication, May 16, 2023) Looking back at the research, it is common for formerly incarcerated students to refer to their identity as clothing (Halkovic, 2015). Articles of clothing can be put on and taken off, as they put on and take off different identities to fit into different spaces and stay safe. Zaynab was intentional about how she would show up that morning of April 15, 2023 proud of her past, her progress and her current identity. She owned it and made it clear to others that her past does not define her. But underneath, her fears and anxiety were still there when she started her day. Navigating College & Stigma: Portfolio Feedback The purpose of the intervention tool, the Pre-College portfolio, was to help this population better navigate their return to college and face the stigma. While all the participants agreed the information in the portfolio was informative and should remain a part of future workshops, they shared some distinct perspectives on the materials and offered valuable recommendations to consider for next years workshop. Where are you in your journey? Lisa made a strong point that everyone is in a different place in their journey (personal communication, Aug 29, 2023), which impacts how helpful the materials are. She would recommend the portfolio to anyone, but it would be especially helpful to those who are still incarcerated and are getting close to a release date, as well as those who are early in the re-entry LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 100 process, so they can feel more prepared for the admissions and financial aid process sooner rather than later. Angela shared a similar message. While Angela believed all the content was helpful, she pointed out that it depends on where the participants are in their journey (personal communication, May 9, 2023). It is difficult to say what the binder should include because everyone is coming at this from different perspectives and different stages of re-entry. Angela explained that she is further along than where others might be, so had she received this binder of materials a few years ago, it would have been more timely and helpful I think it's definitely an individual thing on that, for the most part. I think the longer you wait, for the most part, the more things you have structured in your life, and the harder it, the harder it is to find the room for school (Angela, personal communication, May 9, 2023). Angela did recommend more information on scholarships (Angela, personal communication, April 29, 2023); the other participants excitedly agreed, so this should be added to any future workshop or portfolio content. Angela said, if we can minimize some of that needing for loans, especially for, you know, people thats got all these other things going on, probably probation, and restitution, or whatever, scholarships would be very useful (personal communication, April 29, 2023). Conquering Triggers & Overcoming Stigma Zaynab especially appreciated the admission and financial aid resources funding is a significant obstacle, but she pointed out that some things in the binder could act as triggers depending on the audience (personal communication, April 29, 2023). There is good and bad to this - the intent was to hopefully provide the information and the support that builds the capacity to hopefully push past the triggers, and not let those triggers, or a person with an against voice, LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 101 be a barrier along their pathway. Zaynab speaks to these triggers and all the emotion she experienced coming to campus that Saturday (personal communication, May 16, 2023): it brought back so many memories. Like at one moment I wanted to cry, and one moment, I was really happy because being in that event, I didn't feel that. The moment the, the thing, the thoughts, and the feelings that I had with the previous colleges., and my experience, I didnt have that with Marian University. I felt welcomed. I felt loved. I felt like the energy in the room which is, it was like, Okay, you're here. This is to new adventures. These are for new beginnings, and Lesley, like you, just opened me up with like, welcoming arms. Like from the moment you met me at the door like, Hey Zaynab! It was just, it felt so good, and just when walking in, and being able to speak to other individuals that were just open to talk, and I didn't feel like no one didnt want to talk to me because like, Oh, who is she? Or this and that? Or Oh, she have a background? Or What is she here for? You know, I didn't get that feeling so it was, it was really welcoming. I, I, I say that. (Zaynab, personal communication, May 16, 2023) Zaynab moving in and out of different emotions was triggered by prior lived experiences, but she overcame and pushed through it. It is about building capacity. (Angela, personal communication, 2023, Apr. 15; Julie, personal observation, 2023, Apr. 2023) As for the binder itself and whether it helped to overcome stigma or could help others overcome, Zaynab was torn (Zaynab, personal communication, May 16, 2023): Hm, a good question. That one, it's kind of hard to answer cause it's like, yeah, it helped, but then again it didn't. So, like when I open that book and I[see] in the biography of Angela, which I thought was amazing to seeing that, and reading her biography, like that was really inspirational to me. And then as you flipping through it, you see all these other things, and it was just like, I really have a shot! Like, I could do this! Like, I could really get involved and really, you know, a pays for a, a career that would work for me. But then it was just like, Okay, its a book. (Laughing.) Like, What do I do with it?! You know, like, Just cause it's here, it doesn't mean I might qualify, you know? What if I could really afford to even go to here?! I could barely afford to get here, so it's just like I was thinking about so many things! Like, like, I don't know It, that one was [inaudible 0:25:42 0:25:44] challenging for me cause like like I said, [inaudible 0:25:47 0:25:50] knew me, who looked at that book and say, I can utilize that. I really can. I can it and, and move forward with it, but it's just like that. Old me, in the back of my head like, Okay, what am I gonna do with this? I still havent even gotten my transcripts. I keep saying Im gonna get my transcripts. I havent even bought em yet. I dont have don't have the money to buy these $10 things, you know, and its just like I keep making excuses in the way for myself. Im like, Zay, you could do it! Just do it! It was like it was really challenging. I'm, I'm telling you when I got in there, looking at that book, I felt like I was already enrolled, but it was just in the back of my head is LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 102 like, No, you're not there yet. You're not there yet. You know, but it was really nice to see it so because like everything I mean from just the labels of it like it had the labels on the side where you know which section you wanna go to, or you know, just a little sticky notes, and the [inaudible 0:26:48 0:26:48] the different colors, and everything and it was just like, Lesley, that notebook was amazing! Like I still have that notebook. (Zaynab, personal communication, May 16, 2023) My interpretation of this is that Zaynab recognized the usefulness of the portfolio materials, but her response goes to show that there are such significant financial obstacles for these women - their burden is so heavy that a portfolio of information can only be so helpful. Zaynabs narrative also speaks to Bells study. Bells qualitative study focuses on incarcerated and formerly incarcerated women in the United States, specifically the State of Arizona and how to provide more support to this population at the university level to better prepare formerly incarcerated women for college (Bell, 2020). Bell examines Possible Selves, which is the theory that a persons behavior is largely determined by what they think they will become, what they would like to become, and what they fear becoming (2020, p. 7). The participants in Bells study must understand and explore their past educational selves, their present educational selves and develop a plan for their future educational selves to navigate systems, overcome oppression and move past the stigma. If they can increase self-efficacy and envision a positive future self one who deserves to be in college - it can motivate behavior, just as a feared future self can also motivate behavior and decision making (Bell, 2020, p. 30). Zaynab speaks in multiple spaces to her struggle to overcome past traumas, but when she does, we see a new Zaynab. Experiencing the Workshop: Enhancements for the Future The goal of the workshop was to help this population better navigate their return to college and face past trauma, triggers and stigma and build the capacity to push beyond it. While all the participants agreed the workshop was informative and inspiring and should be offered in LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 103 the future, they shared some unique perspectives on the content and organization of the day, offering valuable recommendations to consider for next years workshop. Emotions & Energy Zaynab shared how she experienced being on campus for the April 15th workshop (personal communication, May 16, 2023): I was welcomed with love, joy, good energy when I walked into that eventI really want to go back to school. I, I just wanna to go and finish and get a degree. I think about [unintelligible 0:27:40 - 0:27:40]. I think about [unintelligible 0:27:43 - 0:27:43]. I think about all of that, so we've kind of been put on hold and sometimes I feel like I do make excuses to it because I'm afraid of what might happen instead of actually just seeing what happens? But I know in my heart that Marian is where I would like to go if I do go back to school. It was just like pulled up to the university. Well first off it was away from where I'm used to so it gives me that peace. Like that self [unintelligible 0:28:15 0:28:15] relaxation on my way, just thinking and like I mean, it was beautiful. Like the university is beautiful. The staff was beautiful. The event was beautiful. The causes of what they're doing was beautiful and I always want to be a part of anything that's willing to help give individuals a second chance at life. (Zaynab, personal communication, May 16, 2023) Angela shared in her individual interview that all the information from the workshop should remain and specifically mentioned financial aid, admissions and the how tos and referenced her own lived experience, working with mothers with justice system involvement, who are considering going back to school (personal communication, May 9, 2023). She explained that sometimes it's that insecurity of not knowing what to do that prevents progress and keeps them from feeling lost in the process, provides some kind of foundation and some confidence (Angela, personal communication, May 9, 2023): So I think all the informative information should stay. So, you know, financial aid, and the admissionswith all those things on how tos because I My own experience and working with individuals, mothers, who are, um, considering going back to school. Who have, um, justice system involvement. There's sometimes it's that insecurity of not knowing what to do that prevents. So that, that, that information I think is really good to stay, um, so the individual doesn't feel lost in the process or feel, or has some information to build on so they, they have some kind of foundation, and, and feel like they have some, um, confidence. LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 104 Ashton shared that she would recommend the workshop and offered the following explanation (personal communication, June 1, 2023): I would recommend it only because it might give somebody a peace of mind. And our somebody's client might really benefit from that. There might be something life changing, and to let others know, like there's not only classes that you have to go sit in all day long, or there's other ways around it. You can, you can do virtual. It was just informative. Kind of put you at ease, and, and kind of put me at ease as far as knowing how the program is and in the steps to get into the program, and what programs are available and, and things like that. So yeah, I definitely would. Ashton went on to explain that not everyone is a strong reader, so she recommended thinking about other audiences who may prefer visual or audio presentation (personal communication, June 1, 2023): I also would think about people that don't necessarily They're not necessarily that strong in reading. So for a, for some, something that could be added is like a QR Code that leads to like a video or something because some people might want to listen. I've been finding out more and more, with like talking to my clients, a lot of them don't read, so they found out about PACE only because they were able to listen to the video. They couldn't read any of the words that were on the screen, but they knew what the lady said. (Ashton, personal communication, June 1, 2023): Zaynabs reply to whether she would recommend the workshop to others touches on the importance of the intervention tool as well (personal communication, May 16, 2023): I absolutely would recommend it. I would recommend it because not only does it help individual, these individuals previous convictions, but these mothers with children to be able to access educationone of the challenges, especially this month, its mental awareness so and they talked about that from disability to, you know, just the mental state, or just you know, um, the resources that you can use, and this binder is compact with so much information that a lot of individuals could take to, to be able to obtain the education that they need, you know, and its, its a really great resource book, and to me I think it's gonna be a great program. Like I, if I wouldve have had this opportunity when I was going through my, my trials and tribulations, I would have hopped on it like that, you know, just because it gave me access to be able to go forward it's just like education is really important, and then with the, the criminal justice system, being able to have an education instead of, you know, being locked up, or having to do probation, or having to do certain things, or having the opportunity to be able to utilize, you know, that time being down, making something positive, I think it's brilliant!... (Zaynab, personal communication, May 16, 2023) LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 105 Employment Services & Career Pathways It was previously mentioned that future workshops need enhanced content in the career services and career pathways category. Advisors lack knowledge on career pathways for formerly incarcerated students, and there are limited and inconsistent services, leaving formerly incarcerated students as their own advocates (Murillo, 2021). There is confusion and mixed feeling among the participants, specifically about how to represent gaps in employment on resumes and how to reply to interview questions (Lisa, personal communication, May 12, 2023): Because even to this day, I have so much trouble trying to answer questions about the gap of employment. Other people come straight out and just tell them, like I worked for the State of Indiana. Well, to me, I feel like that's dishonest because I didnt work for the State of Indiana, I was forced to, you know. So how I, I just don't. I'm uncomfortable answering those types of questions still. Angela agreed with Lisa and recommended inviting more people to future workshops to discuss employment opportunities for those with justice involvement. She offered some ideas on how to strengthen the content that focuses on career services and job opportunities outside of Marion County (Angela, personal communication, May 9, 2023): to talk about employment opportunities or the, the, the resume stuff would be, would great because are ways to There's, there, theres are some really great things that can be done with resumes that are completely legit for people who have Justice System involvement. And maybe even talk about some career ideas that are well matched and suited, and not limited, because I don't want to limit peoples and, but there's some things that we all know that if you have Justice System involvement, you just can't do. Not today, right? Maybe down the line, but not today. So maybe highlighting some, some, some fields that Because some people just don't even know what they what to go back for and so like, you know and, there are a lot of things that dont require licenses and stuff like that, that people aren't thinking about; the nonprofit industry, you know? The addictions, you know, many different business stuff. And theres probably other things too, but you know, just like maybe highlighting some degrees. And then also and I think we talked about this before, some scholarship opportunities, and what would I take away? And I don't know what I would take away because that would be hard, but what I do think, is that if the time was limited to a half day instead of an all day? There would LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 106 have been way more participants. But what do you take out, because it was all, you know, that's where it becomes difficult. Bringing more options to the workshop for career pathways would be helpful to participants like Lisa, who shared that she just does not know what she wants to do or even what options are available for her outside of working in counseling and working with others who are facing addiction. Angela herself may be an appropriate leader of a portion of the career pathways session in future workshops. Angelas idea about a half-day workshop is worth consideration as well. Organization & Design: Virtual Participation & Length Angelas idea about doing a half day workshop is interesting it was a long day for sure, and it may not be best for busy, single mothers remaining engaged all day took capacity of participants and the university volunteers. The group also discussed offering half day workshops on Webex (personal communications, April 29, 2023). Offering multiple workshops shorter in length would allow a more in-depth look into career pathways and degree options, as well as the other content areas in which the participants desired more time and content. Zaynab touched on this a bit in her individual interview (personal communication, May 16, 2023): I don't think I would take anything out because everything works perfectly. If anything, I think that we should use more of the end to maybe give it more time, because that end kind of went over the time, you know, everyone spoke. Like everyone was a deep conversation and so, you know, the enrollment process was really great, but I think that should have been a little bit shorter. So where everybody that was still there got couldve been involved more into that deep conversation that we hadSo I think, like as far as presentation for the Marian University should be shortened, and maybe combined a little bit better, because everything that they talked about was in the binder, which was amazing binder, because you find everything. Like literally things that they didn't even talk about you seen in there. It was like, Oh, okay. Like I loved it(Zaynab, personal communication, May 16, 2023) Zaynab expressed her love of the afternoon session several times in the group debrief and LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 107 individual interview (personal communications, April 15, April 29 and May 16, 2023) it was clearly a powerful experience for her and emerged as a recurring theme in her responses, as well as the others who mentioned it either in the debrief or the individual interview. There could be more time for the deep conversations that inspired them if we divided up content into multiple workshops. We can split out the morning information sessions, enhance them based on the participants recommendations and have a half day workshop that would mirror the afternoon session on April 15, 2023. How might this look? Future workshops could allow participants to attend virtually. Maybe a half day workshop would have been the better move than a full day Angela may be correct that shortening the length of Workshop #1 may attract more participants, and maybe offering a virtual option for those who live in other Indiana counties may be helpful so that they do not have to make such a long drive like Lisa did. I agree with Angelas theory that we lost some participants because they're single mothers. And, that's a significant data point. Angela (personal communication, May 9, 2023) interjected that there was something very special about the in person. I mean, I think you can do it virtually, but then you lose some of that. You lose something there. Ashton seemed to agree with Angela and said that being the only participant on Webex presented some challenges (personal communication, June 1, 2023): I guess the challenge was not being present, and there were people that were present, like if it would have been all online, it would have been, you know different I mean, like to go places, of course you like to take a little field trip, but you know, sometimes your schedule just doesn't allow that. (Ashton, personal communication, June 1, 2023): There is value to the in-person workshop building capacity just by physically showing up; thinking back to Lisas three-hour field trip to the workshop increased her self-confidence, even Lisa acknowledged that this made her aware of her own progress. This aligns with Shermans theory on strengths identification (2017). The formerly incarcerated mothers in Shermans study LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 108 acknowledged the importance of internal strength which they find within themselves by increasing capacity by making positive choices (2017). Lisas progress, choosing to travel to the workshop on April 15th by herself, increased her inner-strength and allowed her to focus on who she is now, not who she was at the time of her crimes. The challenge to continuing the full-day, in-person workshop is that there is so much content to share, and the participants believe that nothing should be eliminated (personal communications, April 29, 2023) so how does this look? Should there be several half-day workshops that focus on specific topics and turning it into a series? Should there be in-person options for Marion and surrounding Indiana counties but also virtual options? There was also the recommendation to offer the workshop and portfolio to mothers who are still incarcerated but close to release and/or mothers who have been recently released (Lisa, personal communication, May 12, 2023). In this way, it would be similar to Project Prove (Case, et al., 2005), a program that began with the women inside prison facilities in Michigan, who then extended their program support and services upon re-entry, which most inside programs do not do. The earlier in their journey, the more useful the intervention (Angela and Lisa, personal communications, May 9, 2023, May 12, 2023). This would first need to be approved by the Indiana Department of Corrections and perhaps also other government agencies or organizations. Technology Enhancements Lisas recommendations about technology and how we may be able to better design a presentation by walking through programs and processes is a fantastic idea and could be easily accomplished (personal communication, May 12, 2023): There's different programs that, um, for technology. Maybe if we could have like a list of what programs are. Like with the library, you know, how we get into that, but what are some of these programs like so PowerPoint. Like I know what PowerPoint is, but what if the next person doesn't, you know? And if I know it, we're lucky, um, but there's just LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 109 little things like that that if an interviewer ask you like, do you know PowerPoint? Do you know this? Do you know this? Like I know those words, but have I ever used it? Do I know? Because offline and online are different? So I think that's the only thing that I would say could be added was just the hesitancy. I know that I experience trying to interview and explain certain things. How do you do that? (Lisa, personal communication, May 12, 2023) This could be touched upon in future workshops, but the ideal place for this content may be the intervention tool: the Pre-College Portfolio. The binder could include instructions and reference websites about PPT, Word and Excel, and we could provide video tutorial links electronically, just as we did with the Canvas and Webex/Zoom tutorials. The Against Viewpoint: How would this impact capacity? In the group debrief, Angela challenged the group to consider inviting the other side to the table. It has been acknowledged that there is a portion of our society who does not agree with free college or for supporting those with backgrounds in higher education. The research shows this and addresses those who believe people with incarceration experience and justice involvement are a safety threat on college campuses. Angelas thought to the group motivated quite a bit of debate among us all (personal communication, August 29, 2023): this is gonna sound weird, but maybe somebody at the table who is against stuff, because for me to understand why somebody has an issue, I need to hear from them. And then you also have the opportunity of seeing how... Like how to change that mindset. Im in bubbles, right? So I'm in recovery bubble. I'm in the just so where I have people that I'm not one of those that stay in that bubble where everybody that I know is in recovery. Like I, I try to stay out of those bubbles. I see people in those bubbles. I see people in, but I'm now in that justice involved bubble. So, like everything, and every, I mean from my job to everything I'm involved in, it's with people on the same side as me. Well, you can't change narratives, and minds, and really make movement with just those people. (Angela, personal communication, August 29, 2023) On the other hand, this could be too much. I intentionally did not include anyone with an LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 110 against view out of concern it would be too much and decrease capacity among participants. My concerns echo what Murillo explains in the Possibility Report that formerly incarcerated students face so many obstacles that if they do not have the appropriate support, they will drop out (2021). I did not want anyone dropping out of the study or leaving the workshop, not to mention carrying the emotional burden of knowing something I planned caused enough pain for one of them to flee. While Zaynab thought Angelas recommendation was potentially good, she also worried how that might traumatize some of the participants (personal communication, April, 29, 2023), because what if they said or did something that offended someone (Zaynab, personal communication, April 29, 2023): I already be feeling like I'm not included in a lot of things, so like just hearing someone you know saying, Oh, I don't feel like this is safe, or I don't feel like you know anyone should want to do this, or just the community or stuff like that, and just hearing the negatives, whatever. It might do something to me to where like It might take me to a different, you know, scenario like, Well, why do I want to be a part of this? You know? Like what if he say something wrong to me? Or what if he say something that I really don't agree and it might just be really hindering me. (Zaynab, personal communication, April 29, 2023) This was my concern when does it become too much for participants who are already so hindered and battle internal struggles daily? Zaynab shared a story about an event she attended in December (personal communication, 2023, Apr. 29). She was advocating for education for formerly incarcerated people but was questioned by the mother of an incarcerated son (personal communication, April 29, 2023): how are you with the prosecutor's office, but you're here advocating? What side are you on? Pick a side. Zaynab felt so embarrassed and carried this home with her after the December event and even into her job. It impacted her work and made her question herself all over again. I loved this conversation. The purpose of the workshop, and the portfolio, and the LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 111 research, and everything happening is about capacity - building capacity to take that next step, or to find a way to make progress. Angelas proposal is intriguing, makes sense and is worth exploration; however, Zaynabs concern is valid. If a future workshop includes an against party and perspective, then the leaders of the workshop will need to move with incredible caution and be able to pinpoint when the heat gets turned up too high, causing participants capacity to decrease to a dangerous level at a pace they may not be able to handle. I confessed to Angela that her idea was recommended by others several months back in the proposal stage of my study, and I decided not to do it because I was scared (personal communication, August 29, 2023). I was worried that putting that person into the day at any point would have the impact that Zaynab described. Thinking back to the afternoon session on April 15, 2023, when we all sat in a circle, talking and engaginghad someone been a part of that who would have spoken out against this population and their deserving of college, what would that have done to the room? I was terrified to do it because of exactly what Zaynab said. This portion of the debrief discussion made me question myself, did I maybe do a disservice to the group, by not having that voice? Would it have increased their capacities with that voice, or would it have maybe had the opposite impact, and turned off any of the participants, and made them feel unwelcome and maybe even walk out? This was not an anticipated question, but I asked the group due to how the debrief unfolded (personal communication, April 29, 2023). Lisa shared that she probably would not have felt as comfortable (personal communication, April 29, 2023). I don't feel like I would have been as comfortable, especially if someone spoke out against education for incarcerated or formerly incarcerated people (Lisa, personal communication, April 29, 2023). She quickly reminded me of the backlash weve LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 112 witnessed over free college. College students resent that justice involved students are privileged and special, getting free access to resources and education that they did not have and believe incarcerated individuals were damaged, dangerous, aggressive, and ignorant (Ott & McTier, 2020, p. 299). When Lisa explains that she earned some of her college credits while being incarcerated, some have asked, Well, don't you have to take it over because how could it be the same? They assume their education was handed to them or that it was watered down. Lisa concluded that it would have decreased her capacity (personal communication, April 29, 2023): You know, so having to face that. I don't know because Ive come to find out, like I've come to realize that my go to instead of anger is withdrawal. I like to just shut down and avoid. I avoid every situation that I'm not comfortable in instead of being angry about it, and I think that that could have been possibility for me as just to avoid the whole conversation when it would turn to that. (Lisa, personal communication, April 29, 2023): Zaynab agreed with Lisa and took it further by explaining much of our society does not want them in the community much less the classroom. She wants to find a way to share the lived experiences of individuals who are coming out of prison, to help society understand what they must go through, trying to still feel welcome in the world that's so cruel because of their previous involvement with their criminal justice system (personal communication, April 29, 2023). Angelas awareness of the others apprehension about bringing an against viewpoint into the space, she offered a compromise to invite someone with an against viewpoint to be an observer and listen in on a future workshop from the balcony just listening, not participating or engaging. The observer could be given a pre-survey and then be given a post-survey to determine if any of the content or stories of the participants opened the observers heart and mind (personal communication, April 29, 2023). This could be helpful to determine if a workshop LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 113 like this may open minds of others who may be against second chances toward education and reentering communities. This would have been well beyond the scope of my study but is a legitimate idea for future research and future workshops. It may help us identify where we need to chop away at things (Angela, personal communication, April 23, 2023, Apr. 29) in hopes of making progress. This would be a test of Allports intergroup contact theory, which claims that prejudice is learned when a particular group is assigned objectionable qualities in society (1954). There is evidence to support intergroup contact theory regarding formerly incarcerated people the more exposure to this population, the more the majority group softens (Binnall et al., 2021). It would be interesting to see if an observer with an against viewpoint might soften toward the participants after hearing their narratives. LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 114 SUMMARY OF FINDINGS & DISCUSSION Reflecting on the mothers voices in the debrief and interviews provides insight into the research questions - what was learned, what was overlooked and what remains a mystery in need of further research. What surfaces as most interesting was the underestimated difficulty in getting the mothers to physically show up on the college campus; many limitations were shared by anticipated participants from work and childcare issues, to conflicts with childrens spring sports activities, but it leaves me curious about what was running underneath all those conflicts and whether fear, self-image and anxiety was operating beneath the surface. This may be connected to what was uncovered about the length and delivery of the workshop itself. It was a full day workshop on a springtime Saturday, and the participants wondered if it was just too much for some of the women. One idea was to have a half-day, inperson workshop like the afternoon session that focuses on emotional capacity and community, especially since the binder covered the majority of the mornings topics. Another option was to keep the full day but offer it during a different time of year or offer multiple workshops yearround some of them in-person and some of them via Webex to accommodate a larger audience and potential students throughout the state of Indiana. A series of mini workshops may better meet the mothers where they are in their lives; there should be multiple ways for the mothers to enter their journey to college. Research Questions What are the experiences of formerly incarcerated mothers in their journey to pursue college? The participants described their experiences pursuing college to be traumatic and hindering. Though the mothers are in different phases of their journey, they all spoke to varying levels of fear, shame, and anxiety over college. From being shamed through an admissions LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 115 process and being removed from classes a few weeks into a semester, to taking on a fictional persona to hide her past, these mothers shared their lived experiences and how those experiences contributed to low self-esteem and impacted how they showed up at the workshop on April 15th. A few shared that even asking questions was too much for them. Regardless of where the participants were in their lives and how long since re-entry, they were each nervous in their own way and had fears and uncertainties walking through the door that day on campus. Just showing up in that space increased capacity. All four of the participants said they were blown away by how supportive the Marian faculty and staff were and how welcome they felt in the workshop space. I learned how important it was for them to feel a sense of belonging on a college campus after prior lived experiences left them feeling judged and unwelcome. I learned how painful their previous experiences were and how that limited them and their college self-efficacy. I learned that the participants were acutely aware of their surroundings; they noticed the body language of each other and of the faculty and staff members who entered the space as guest speakers and presenters and sensed their open mindedness, which helped to lessen their fears and decrease anxiety as the morning sessions progressed. The more support they receive and the more members of the college community who become available to help them through basic barriers, such as completing an online application and answering questions about technology, financial aid and resources, their anxiety decreases, and college self-efficacy and capacity increases, slowly creating a sense of belonging. LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 116 How do the formerly incarcerated mothers perceive external obstacles to hinder their capacity as they pursue post-secondary education? I learned that not having basic information can deter them from pursuing college because of the fear of asking questions and being perceived as incompetent. One of the participants explained that one of the biggest hurdles is not knowing what to ask whom and feeling intimidated to ask a question. There is also the fear of being asked questions about their past and crimes; this is perceived to be a significant obstacle that hinders their desire to continue with the admissions and enrollment process. The significance by which the external obstacles have hindered the participants was underestimated. Participants shared their triggers and the emotional ups and downs they experienced on previous journeys to college and the anxiety brought on by memories of being turned away and judged, inhibiting their motivation to return. How do the formerly incarcerated mothers perceive the stereotypes about mothers with criminal histories and how does the stigma impede their capacity to return to post-secondary education? I learned that mothers are all in different places because of the ages of their children. Mothers with young children face different obstacles than mothers with grown children. I learned that the mothers were significantly torn on choosing themselves over their children, and unknowingly, I put many of them in this position because to attend my workshop, they would have had to have missed a childs sports practice or game or other activity. Many anticipated participants had conflicts surrounding children which prevented them from attending the workshop. I underestimated how challenging a choice like this was for the mothers. What I was LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 117 unable to learn was what was at the core of this inner struggle to choose themselves to choose their own betterment or advancement. Who did they think they were betraying? This may be explained, in part, by one of the women in the pre-diagnostic interview; K.B. explained that coming out of incarceration, there is always that pressureI cannot dare miss a soccer gameeven if I justify it in my own head, then I feel the guilt and the shame when I am around other people (personal communication, 2021). Mothers face gender bias because they have not or do not sacrifice themselves completely for their children. This issue presented itself when several participants were faced with choosing themselves by attending an all-day Saturday workshop for college or attending their childs soccer game or other sporting event or activity. What I did not learn from the participants in this study was how they perceive these societal pressures and stereotypes about being considered a bad mom as limiting capacity to return to college. Does being in Mitchell & Davis bad mom box (2019) increase anxiety about returning to the college campus and classroom? The participants shared that being a mother, especially a single mother with younger children, does present additional challenges and barriers; however, it was not surmised that societal stereotypes about mothers and the double stigma further complicated their capacity to return to college. This remains a mystery worthy of additional exploration in future workshops and interventions. How can Pre-College Workshops help formerly incarcerated mothers build capacity within themselves to overcome the external barriers blocking their pathway to college? The participants shared that they would recommend the workshop and found the content to be helpful, but it was clear in their debrief and individual interviews that the afternoon session was the most powerful. Shortening the morning session, especially since much of the material LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 118 was available in the portfolio, to focus more heavily on the afternoon session would have been preferred by the participants. They all agreed that the afternoon session seemed to have special significance, as they were allowed the space to reflect, breathe and share their stories; the faculty and staff shared along with the participants, developing a deep connection, which appeared to have significant meaning and lasting impact. Curiosity remains as to whether day care availability the day of the workshop would have increased the number of participants. Taking it a step further, had their children been included in the day, how would that have decreased anxiety over choosing themselves over their children? In future workshops, exploring how the mothers children can be engaged in workshop sessions as individuals and alongside their mothers will be a priority; policies and procedures at the organization for having children on campus would be considered. As for intended audience, only mothers with former incarceration experience were invited to be participants, but the content provided in the workshop and portfolio, arguably, could be for any individual with incarceration experience or justice involvement. Although that space was distinct to mothers, the content of the workshop and portfolio could be for anyone. How can a Pre-College portfolio help this population better navigate their return to college and face the stigma? All participants agreed the information in the portfolio was informative and should remain a part of future workshops to varying degrees but also offered valuable recommendations to consider for future workshops. A key takeaway was that each mother is in a different phase in her journey which influences how helpful the materials are. Participants would recommend the portfolio to anyone, but it would be especially helpful to those who are still incarcerated and close to a release date, as well as those who are early in the re-entry process. It was LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 119 recommended to coordinate with leadership at the department of corrections on how materials may be shared with those who are in their final stages of incarceration. Upon re-entry, the mothers often face significant financial and technology related barriers. While the portfolio information was regarded as valuable and made them feel excited and welcomed, it then also triggered concerns about finances and other barriers, making them question how possible college really is for them. More information on scholarships and grants would be helpful to supplement financial aid. The participants agreed that there should be additional resources on how to navigate these obstacles, such as applying for scholarships. More video presentations and tutorials, walking through programs and processes, such as using the online library, creating PowerPoint presentations, downloading word and excel and uploading documents and video to e-mail, were recommended. The portfolio helped to overcome stigma but acted as a trigger in other ways. One participant described how she was moving in and out of different emotions when reviewing the portfolio; it triggered prior lived experiences, but she overcame and pushed through it. She recognized the usefulness of the portfolio materials, but her response goes to show that there are such significant obstacles for these women - their burden is so heavy that a portfolio of information alone can only be so helpful. Overcoming and believing the are college material may be the biggest barrier. I learned that Bells qualitative study, which examines Possible Selves Theory - the theory that a persons behavior is largely determined by what they think they will become, what they would like to become, and what they fear becoming (2020, p. 7) may be the most significant factor in increasing capacity and self-efficacy. While the workshop and portfolio are valuable interventions and tools to increase self-efficacy, the mothers must be able to envision a LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 120 positive future self one who deserves to be in college. This was confirmed by the participants narratives. LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 121 FUTURE RESEARCH & CONTINUING THE WORK There is much work to be done, and I would like to continue some of the work beyond the completion of this study and degree. Areas in need of the most work and the most priority revolve around establishing degree options, career pathways and community partnerships; developing a mentoring program, and applying for grants to offset financial barriers. We also need to get the word out statewide to Indiana communities that justice involved mothers are welcome. While the workshops and portfolio may be helpful to a broader audience, the focus will continue to be mothers with former incarceration experience and justice involvement. Degree Options, Career Pathways & Partnerships Help with job placement, community partners and pipelines, and career pathways in Indiana outside Marion County is a priority. Lisas frustration with a lack of options in Elkhart County is evident when she explains, There is nothing here for us! Like I couldn't even get a, a job at the license branch as a freaking like receptionist or whatever, you know? It's because I have the past that I have, so I really don't know where to go. (personal communication, April 29, 2023). Even with her bachelors degree to be earned this August 2023, what job can she land? And will it be a job that pays enough to repay student loans? For mothers like Lisa, who do not believe it is a healthy choice to pursue a career in counseling and addiction recovery, what are other degree options lead to career that pay enough to support a family and repay debt? Angela recommended establishing a pipeline to the prosecutor's office and their current initiatives in Marion County to eliminate obstacles to jobs and to college, such as the expungement program and drivers license reinstatements (personal communication, May 9, 2023). Angela also recommended that we look at a very specific population, and doing the mothers that have been formerly incarcerated, I think they're I think they belong with Marian. LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 122 They belong with you, I mean, the research has been done at Marian. I think that is a great next steplooking at some programming that fits them. (personal communication, May 9, 2023) Mentoring Program Students and formerly incarcerated mothers who authored Spotlight on Indiana: Barriers to higher education for incarcerated and formerly incarcerated students said that peer-to-peer mentoring would do wonders (2019), but so few of these programs exist. San Francisco State and Rutgers are mentioned in the research for building peer-to-peer support networks, mentoring programs and other support programs for college students with criminal records (Ott & McTier, 2020). University staff and faculty could have an opportunity to mentor a new student, from enrollment and admissions through curriculum and job placement. Financial Obstacles Zaynab asked about financial help for mothers returning to college and their children in the group debrief (personal communication, April 29, 2023): Now is there ways where like we could like get grants for these women with children who have stipulations to help them that, that keeps them from moving forward, as far as like giving grants like every semester to kind of help cover gas, or maybe utility bills, from the ones that are not working full time, or maybe just need a little assistance so they continue, you know, pursuing their education. Like how do we go about as far as finding the resource for that to where we make the program successful, so we get more outcome from the program when we have more resources to be able to help these individuals? (Zaynab, personal communication, April 29, 2023)Because for me, I'm a single mother of threeI'm still trying to be involved in, you know, sports for my children, going to church, still being a part of different organizations, and sometimes like, Hey, I could use the extra funding, but you know, individuals that coming out of those situations, and just who don't have housing, or who don't have jobs. Or, or in the process of looking. Those extra funds will come a long way to be able to help them utilize that because cause when, when. One thing I do know, when you're coming out of transition from that type of lifestyle, and you have the opportunity to do better, as long as the doors are constantly keep opening, or at least you're getting the right resources, you're gonna to be successful. but when you're coming out of that situation, and youre constantly getting doors blocked, and you don't have the financial help that you need, you're going to drop tremendously, and youre gonna back to your old lifestyle, and you're gonna go back to LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 123 that. So it's just this program I think is going to be amazing and I cannot wait to see where this goes. (Zaynab, personal communication, May 16, 2023) The workshop and portfolio offered wonderful resources on which we can expand and contributed to increased capacity among participants, but the financial burden still lingers. The university can open their doors, as Zaynab explains, but if the women do not have the financial help they need, those doors are blocked again. But it, its always gonna come down to the financial component of the biggest barrier. That's gonna always be the biggest barrier, so yeah (Angela, personal communication, April 29, 2023). Committee Formation: Faculty & Participants Come Together This discussion motivated me and the participants, Angela, Zaynab and Lisa to continue the work and form a committee group with five of the faculty volunteers from the workshop on April 15, 2023. This will bring faculty to the same table as justice involved mothers to work on progress together which will only continue to build capacity. The afternoon of the workshop was such an incredible experience for everyone that we discussed how it might look if we formed a committee to continue the work and what would that work look like? Our priorities will include establishing more contacts and community partners who can help advise on degree options and career pathways for our justice involved mothers who want to go to college, as well as exploring a campus based mentoring program. Establishing a mentoring program will be the first goal of the group. When formerly incarcerated students enroll, they struggle to get guidance from academic advisors and are limited in access to peer mentors and university resources (Bumgardner et al., 2019). The more we can connect with formerly incarcerated students right away, the better we can design their pathways to re-enter education (Bumgardner et al., 2019). The women have shared that the financial component to return to college is often the biggest barrier, so long term, the group will explore local non-profits with whom to partner on grants and LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 124 scholarship opportunities to supplement financial aid and pay for college-related expenses, such as textbooks, computers, and transportation. Our first meeting was Tuesday, July 25th. Lisa pointed out that staying focused may be the most challenging work the upkeep of the program, future workshops and the priorities of the committee (personal communication, May 12, 2023): So is your next step, because I know you, I see you not giving up; therefore I see your final like thesis paper, whatever it is that you have to you know, the, the final part of this, being put to use in a place that affects more than just Marian and that doesn't even have to be directly from you. You know? I think that as far reaching as it has been so far, that it's going to be shared and I feel like your next step is the upkeep of it I would say, because I know that you're not the type just to, to give up on something that you start. It's been proven. Look at the school. Look at, look at the college prison, you know? So I feel like that would be your next stepWe'll probably start with Marian, and then, you know, once Marian starts something, and it the word-of-mouth travels. Like, Marian has this type of students and they're succeeding, then other colleges are gonna do it, and it's going to be more accepting. Colleges might be more accepting, and understanding, maybe even a little bit more helpful to individuals, not just mothers, not just women, but individuals that are choosing the right path, after the wrong one. You know? I think that by Marian opening their arms to people trying to think of the word that I want to use. What is the word I'm looking for? But not like norm, you know? The, the not Opening their arms to unnormal college kids, I know I have almost a bachelor degree, and I don't know if unnormal is word, but I'm using. (Laughing.) (Lisa, personal communication, May 12, 2023) The raw advice of the women on how to improve their experiences and our continued recognition of their guidance on how to make progress around obstacles along their pathways embraces this phenomenological approach which is motivating us to create an infrastructure of support for the women who will continue hereafter. Social Media & Advertising Lisa tells us word-of-mouth travels (personal communication, May 12, 2023), so we need to get the word out! What's the next steps for higher education? Ashton spoke to the power of social media and advertising an effort to get the message out there and send an invitation LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 125 that the college or university truly welcomes this population and that the organization is taking steps to remove some barriers and obstacles (Ashton, personal communication, June 1, 2023): I think it should be more advertisement because people don't really know about those programs. We know that its a school, but we don't know that we can apply to that school, and we won't be denied, or questioned about our background. So just more advertisement. Like if I was to see that flyer on a billboard, I would be like really happy. You know, or even a sign a yard sign. You know, to let people know, like you're not excluded, because I never even knew that that was a thing until Ang walked up and was like, Hey, can you participate in this with me, or would you like to? I looked at the flyer, and I found out that day. But it's not advertised that people can, you know, come to the school and, and they'll be given a chance. It's, it's just not advertised. I feel like. I don't know if there's such a thing, but so, at one of my previous jobs, I was Community Outreach. You know what I mean? And I got the name out in a matter of months. People didn't even know that my old job still was open. I got on Facebook, and I got like a hundred an fifty-two K shares. I had to shut down the post because I kept getting messages from around the world at all hours of the night. I think that advertisement is the key, uh, because the way of the world now is technology, and if it's not technology, everybody travels. Everybody is traveling on a bus or a car. They're gonna look at a sign. (Ashton, personal communication, June 1, 2023) LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 126 CAPSTONE SUMMARY Halkovic & Green (2015) send the message that by embracing the gifts of formerly incarcerated students, institutions of higher education put themselves in a unique position to help them make the transition from prison to community. This study presented an intervention to identify the structural and internal barriers that hinder formerly incarcerated mothers progress to gain the support and services to better themselves, redefine self-image and increase their capacity to move through the stigma on their own, while also making progress in our institutions and communities in which we invite the gifts of those who have been stigmatized to strengthen our spaces and open our minds. My life has been transformed and enriched by the incarcerated and formerly incarcerated women, mothers and their gifts. Danny Murillos Possibility Report was motivation for my intervention. This was a meaningful goal of my capstone to create a local blueprint (2021) for formerly incarcerated mothers who pursue college in Central Indiana, narrowing the scope to address a few significant college specific structural barriers unique to formerly incarcerated mothers, and design a portfolio and pre-college workshop program to help prepare mothers for college. This was accomplished, but at the recommendation of a faculty volunteer, what we have looks more like a compass than a blueprint (personal communication, 2023), a compass because it is vital for navigation, and we hope it keeps us making movement in positive directions. The focus on college self-efficacy in Bells study also energized this study the idea that increasing a persons college self-efficacy while decreasing their perception of structural barriers, will prompt greater motivation to pursue post-secondary education (2020, p. 7). When they believe they can do it and believe they belong in college and have every right to that LIVED EXPERIENCES OF FORMERLY INCARCERATED MOTHERS 127 education, the structural barriers do not seem so insurmountable, and this is demonstrated through much of Zaynabs narratives and lived experiences. Murillo and Bell heavily guided and informed my intervention, as well as the literature from other scholars and formerly incarcerated women on structural barriers, the power of selfesteem and self-efficacy. In exploring the lived experiences of formerly incarcerated mothers, my intention was to share their struggles, challenges and hardships but also their victories and successes - in hopes we may replace prejudice and judgment with empathy and opportunity. The incarcerated and formerly incarcerated women from the Indiana Womens Prison drove this study, some of whom are the authors of the Lumina Report, Spotlight on Indiana: Barriers to higher education for incarcerated and formerly incarcerated students. They do much of the work for us; they use their voices and tell us what we need to do if we listen. Their recommendations guided my interventions focus on building deliberate pathways for the formerly incarcerated in Indiana to enter campus and experience college, not just as students but gift-givers. Its in the rawness of the womens words that we find truth unaltered by our own interpretations it is where the essence lives in a phenomenological, authentic approach which really spotlights the voices of the women in the study. Continual recognition of their advice and feedback will strengthen future workshops and initiatives. 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ProQues 1 Appendix A: Questionnaire for Formerly Incarcerated Mothers Pre-Intervention Workshop #1: Intervention Tool - Pre-College Portfolio 1. Please share your experience with re-entry pertaining to your pathway to college. What was it like for you? What were your biggest challenges or obstacles? 2. How did your role as a mother impact your re-entry? How did it impact your return to college? 3. Please describe your experiences with stereotypes and stigma upon re-entry and your return to college. 4. For the Pre-College Portfolio, please mark which of the following content would be helpful in the table below by placing an X in the middle column, then please share how and why the content would be helpful to you in the far right column: Portfolio Content Budgeting and personal finance information How to guide on e-mail, Word, and basic technology Library resources Resume building Job searches and interview preparation Financial aid, Pell and E-mail etiquette & communications with professors Transcripts and transfer credit Degree options and career pathways X if Explanation of how and why it would be helpful. helpful 5. Please list anything that you believe would be helpful to have in the Pre-college Portfolio that is not listed above. Appendix B: Letter of Consent, Questionnaires Formerly Incarcerated Mothers Pursuing College __________, 2022/2023 Re: Capstone Project for Ed.D. in Organizational Leadership: Lived experiences of formerly incarcerated mothers: Navigating societal stigmas and barriers impeding their pathways to pursue higher education Dear Participant: You have agreed to engage in a Pre-College Workshop Series, which includes responding to the attached questionnaire. Responses will be used to prepare the Pre-Intervention Workshop Tool, the Pre-College Portfolio, which will be a resource in the Pre-College Workshop Series for mothers with incarceration experience who are pursuing college. Other mothers with incarceration experience have been invited to participate in this research by responding to the attached questionnaire. The information you provide may offer a better understanding of the experiences of formerly incarcerated mothers who pursue a college education and the structural barriers experienced in the college process. You are not being compensated for responding to the questionnaire, and your responses are being given voluntarily. The responses to these questionnaires will be used in a qualitative capstone study, defended to a committee in an open public forum to satisfy a doctorate degree requirement, and may be published. Your name and responses will remain confidential. You will be referenced and cited as you permit and approve in writing. You may withdraw your consent at any time and may decline to answer any question that may make you uncomfortable. Your participation is valued, and your responses are appreciated. Sincerely, Lesley Neff Lesley Neff Ed.D. in Organizational Leadership Student Marian University 3200 Cold Spring Road Indianapolis, IN 46220 Appendix C: Letter of Consent, Workshop #1 Formerly Incarcerated Mothers Pursuing College __________, 2022 Re: Capstone Project for Ed.D. in Organizational Leadership: Lived experiences of formerly incarcerated mothers: Navigating societal stigmas and barriers impeding their pathways to pursue higher education Dear Participant: You have agreed to engage in a Pre-College Workshop Series, which includes in-person attendance to Workshop #1, on Saturday, __________, 2023, from 8.a.m until 5.p.m. An agenda will be provided in advance. Other mothers with incarceration experience have been invited to participate in this research by attending and engaging in Workshop #1. Your participation is voluntary, and you are not being monetarily compensated for this participation in Workshop #1; however, breakfast and lunch will be served. Gift baskets and gift cards will be distributed at the end of the workshop. Observations and recordings from the Workshop #1 may be included in a qualitative capstone study, defended to a committee in an open public forum to satisfy a doctorate degree requirement, and may be published. Your name and responses will remain confidential. You will be referenced and cited as you permit and approve in writing. You may withdraw your consent at any time. Your participation is valued and appreciated. Sincerely, Lesley Neff Lesley Neff Ed.D. in Organizational Leadership Student Marian University 3200 Cold Spring Road Indianapolis, IN 46220 Appendix D: Letter of Consent, Workshop #2 Debrief Formerly Incarcerated Mothers Pursuing College __________, 2022 Re: Capstone Project for Ed.D. in Organizational Leadership: Lived experiences of formerly incarcerated mothers: Navigating societal stigmas and barriers impeding their pathways to pursue higher education Dear Participant: You have agreed to engage in a Pre-College Workshop Series, which includes Webex virtual attendance and participation in Workshop #2, on ___________, __________, 2023, from ___ until ____. This will be an opportunity to debrief on Workshop #1, and your feedback will be invited and encouraged. Questions will be provided in advance to prepare for discussion. Other mothers with incarceration experience who attended Workshop #1 have been invited to participate in the Workshop #2 debrief. You are not being compensated for your participation in the Workshop #2 debrief via Webex, and your feedback and participation will be given voluntarily. The Webex will be recorded and transcribed for accuracy and will be used in a qualitative capstone study, defended to a committee in an open public forum to satisfy a doctorate degree requirement, and may be published (the final paper, not the Webex recording). Your name and feedback will remain confidential. You will be referenced and cited as you permit and approve in writing. You may withdraw your consent at any time and may decline to answer any question posed in the Workshop #2 debrief that may make you uncomfortable. You may decline feedback at any time during the Workshop #2 debrief. Your willingness to participate is appreciated. Sincerely, Lesley Neff Lesley Neff Ed.D. in Organizational Leadership Student Marian University 3200 Cold Spring Road Indianapolis, IN 46220 Appendix E: Letter of Consent, Interviews Formerly Incarcerated Mothers Pursuing College __________, 2022 Re: Capstone Project for Ed.D. in Organizational Leadership: Lived experiences of formerly incarcerated mothers: Navigating societal stigmas and barriers impeding their pathways to pursue higher education Dear Participant: You have agreed to engage in a 60-minute interview, either via phone call or Webex, about how you experienced the Pre-College Workshop Series & how you received the Pre-College Portfolio. Other mothers with incarceration experience who attended Workshop #1 have been invited to participate in follow-up interviews. Attendance and participation in Workshop #1 are required for interview consideration. Your interview will be recorded and transcribed for accuracy. You are not being compensated for this participation, and your participation is voluntary. The results of this interview and feedback provided will be used in a qualitative capstone study, defended to a committee in an open public forum to satisfy a doctorate degree requirement, and may be published (the final paper, not the interview recording or transcription). Your name and feedback will remain confidential. You will be referenced and cited as you permit and approve in writing. You may withdraw your consent at any time and may decline to answer any question posed in the interview that may make you uncomfortable. Your participation is appreciated. Sincerely, Lesley Neff Lesley Neff Ed.D. in Organizational Leadership Student Marian University 3200 Cold Spring Road Indianapolis, IN 46220 6 Appendix F: Analysis of Chosen Intervention Selection of Intervention Before selecting the Marians Pre-college Workshop Series and Pre-college Portfolio tool, several other interventions were considered: Option #1: Building a program which would run out of a non-traditional department at the university to encompass all service and support needs of formerly incarcerated mothers to clear their paths to college to include support for housing, transportation, career services, day care, financial literacy and counseling was considered. This would require too many other stakeholders, factions and forces at the organization. There is a low likelihood of the researcher being able to execute such a massive intervention in a short period of time. It would also be beyond the researchers capacity to influence so many factions and stakeholders and could potentially jeopardize the researchers authority at the organization and conflict with the status of another program initiative. Option #2: Developing a semester long pre-college course was an option. This would be ideal as it would allow for more time to develop a comfort level in the environment and build a stronger capacity to face feelings of shame and guilt enough to come back into the classroom. Course facilitators could walk the participants through all the processes and get them firmly established at the institution, and more relationships could be developed and grow over 16 weeks. This option was deselected because of logistical and financial barriers and time constraints. Many participants may have to travel 60+ miles to Indianapolis. They work full time jobs - many work multiple jobs, and it is anticipated that many participants will be single mothers. To take part in a 16-week class on campus 7 would be burdensome, even if delivered in a hybrid format, and many participants may be unable to complete the course and drop out at various points in the process. Even if the logistics could be worked out with the participants, there would be financial barriers; it would not be an affordable option in the budget to compensate the participants for food, gas and time for 16 weeks. A virtual option was considered, which could be possible for some meetings, but due to the adaptive nature and sensitive material, a face-to-face component seems important, at least early on. Option #3: Developing workshops or training sessions for faculty and staff who work with non-traditional populations, specifically formerly incarcerated mothers, was considered. While this is needed and could perhaps, in future research and projects, be created as a prerequisite for faculty and staff who participate in the Marian University Pre-college Workshop Series, it veers away from the true adaptive challenge in this study which is to provide the women with a support service to help them build their own capacity and face the stigma and stereotypes head on; therefore, this option was deselected. Due to the potential political and financial barriers, the mindfulness of the adaptive leadership framework, and the time constraints of the first three options, the Marian Pre-college Workshop Series, with the Pre-college Portfolio tool, was selected as the intervention. This is the most reasonable ask of stakeholders and participants who are at maximum capacity and may be reluctant to dedicate too much volunteer time, especially without compensation, as most staff and faculty are at maximum capacity with work and family. This option has the most potential for making progress on an adaptive challenge with a focus on a distinct population of students for this study; however, the potential of this intervention is boundless in that a workshop series 8 like this can be adapted to appeal to other non-traditional student populations at Marian University.  ...

... Asian Spine Journal Asian Spine Journal Basic Study Asian Spine Spine J 2024;18(1):1-11 https://doi.org/10.31616/asj.2023.0203 Lumbar in Supine versus Weight-Bearing MRI 1 Lumbar Spine Anatomy in Supine versus WeightBearing Magnetic Resonance Imaging: Detecting Significant Positional Changes and Testing Reliability of Quantification Niladri Kumar Mahato1,2,3, Paramanand Maharaj4, Brian C. Clark2,3 1 College of Osteopathic Medicine, Marian University, Indianapolis, IN, USA 2 Ohio Musculoskeletal and Neurological Institute, Athens, OH, USA 3 Department of Biomedical Sciences, Ohio University, Athens, OH, USA 4 Department of Radiology, Eric Williams Medical Science Complex, University of the West Indies, St. Augustine, Trinidad and Tobago Study Design: Testing between and within group differences and assessing reliability of measurements. Purpose: To study and compare lumbar spine morphology in supine and weight-bearing (WB) magnetic resonance imaging (MRI). Overview of Literature: Upright lumbar MRI may uncover anatomical changes that may escape detection when using conventional supine imaging. This study quantified anatomical dimensions of the lumbar spine in the supine and WB MRI, compared specific morphometric differences between them, and tested the intra-rater reliability of the measurements. Repeated measures analysis was used to compare within- and between-session measurements performed on the supine and WB images. Reliability and agreement were assessed by calculating intraclass correlation (ICC) coefficient. Methods: Data from 12 adults without any history of back pain were used in this study. Sagittal T2-weighted images of the lumbar spine were acquired in the supine and WB positions twice (in two separate sessions scheduled within a week). Linear, angular dimensions, and cross-sectional areas (CSAs) were measured using proprietary software. Supine and WB data acquired from the two imaging sessions were tested for intra-rater reliability. Quantified data were normalized for each session to test the significance of differences. ICC was calculated to test the reliability of the measurements. Results: Linear, angular, and CSA measurements demonstrated strong within-position (supine and WB) correlations (r -values, 0.750.97). Between-position (supine vs. WB) differences were significant for all measured dimensions (p <0.05). Between-session measurements demonstrated a strong correlation (r -values, 0.640.83). Calculated ICC showed strong agreement among the measurements. Conclusions: Anatomical dimensions of the lumbar spine may demonstrate consistent and significant differences between supine and WB MRI for specific structural parameters. Keywords: Back pain; Sagittal; Spinal canal; Intervertebral; Degeneration Received Jun 30, 2023; Revised Aug 6, 2023; Accepted Aug 13, 2023 Corresponding author: Niladri Kumar Mahato College of Osteopathic Medicine, Evans Center, Marian University, Indianapolis, IN 46222, USA Tel: +1-812-603-3307, Fax: +1-317-955-6418, E-mail: nmahato@marian.edu ASJ Copyright 2024 by Korean Society of Spine Surgery This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Asian Spine Journal pISSN 1976-1902 eISSN 1976-7846 www.asianspinejournal.org 2 Niladri Kumar Mahato et al. Introduction Diagnostic magnetic resonance imaging (MRI) for low back pain (LBP) may not conclusively detect structural causes associated with the pain or dysfunction [1,2]. Studies have indicated that routine MRI, acquired in the supine position, could be inadequate or inconsistent in detecting structural changes causing mechanical or nonspecific back pain compared with imaging acquired in a weight-bearing (WB) position [3,4]. Conventional supine MRI used to diagnose LBP and spondylolisthetic segmental instability does not involve physiological weight bearing and may miss the detection of narrowing of the spinal canal, disks, and intervertebral foramina, as a cause of back pain, which could be identified upon imaging in WB positions [5,6]. Treatment decisions for disk herniation, canal stenosis, and intervertebral foramen narrowing are made based on clinical evaluation, which is supplemented by related radiological assessment. Accordingly, the effects of WB on diagnostic imaging may warrant further investigation [7,8]. Although WB MRI is not yet a standard for the diagnostic evaluation of LBP or listhetic segmental instability, instrumented spine loading in the supine and WB (sitting and standing) positions has been documented in experimental and diagnostic imaging studies [9-13]. Because MRI acquisition usually takes longer than X-ray techniques, MRI protocols could be physically challenging for patients with concurrent back pain. In contrast, spinal soft tissues are best visualized using MRI, and WB MRI has been demonstrated to be critical in detecting structural causes of LBP that may slip detection with imaging in the supine position [9-11]. Although some studies have examined the ability of positional MRI to uncover anomalous spine anatomy in patients with symptomatic lumbar stenosis, normative data comparing supine and WB lumbar spine anatomy in healthy individuals are limited, particularly in terms of back pain literature. Additionally, although positional MRI data comparing physiological effects of spine loading in healthy individuals are limited from single-session studies, tests for intra-rater reliability and statistical comparisons between positional data from multiple sessions are not readily available in the literature [8-12]. Our study used open WB MRI for lumbar spine imaging in a cohort of healthy participants (1) to detect the specific dimensions of the spine affected by positional changes in imaging, (2) to test whether WB induced sig- Asian Spine J 2024;18(1):1-11 nificant changes in these dimensions between the imaging positions, and (3) to evaluate the consistency of the within- and between-positional measurements for the detected dimensions. Materials and Methods This descriptive imaging study included a cohort of healthy participants to quantify morphometric changes in their lumbar spines induced by WB by comparing specific dimensions in supine versus WB MRI images. Additionally, we assessed the statistical significance of positional changes following WB and evaluated the consistency of our measurements using intra-rater reliability testing [13]. Imaging was performed in two separate sessions; each session involved imaging once in the WB position and once in the supine position. 1. Participant selection In this study, 13 volunteers aged 1860 years (mean: 3812 years; seven females and six males) participated. The exclusion criteria were as follows: individuals who reported LBP with a 1 on the numeric pain rating scale, those with a history of spinal surgery, those with any orthopedic or neurological impairment, those with cancer or tumors, those with cardiopulmonary disorders, those with clinical depression, and those who were taking medications or supplements for LBP. General compatibility for MRI was assessed; subjects with a body mass index (BMI) >32 kg/m2 or those with any physical limitations that impaired their ability to stand inside an open MRI system were excluded. Visit 1 included study orientation and subject consent. Visits 2 and 3 were scheduled 1 week apart at the university MRI facility [14]. One male participant dropped out of the study for personal reasons. Because of the relatively younger age of the study participants, none of the images showed any age-related degenerative changes that may have affected the anatomical parameters measured, except for two participants, who showed some evidence of age-related degeneration at their L3L4 and lumbosacral levels. Informed consent was obtained from all individual participants included in the study. The Institutional Review Board approved the study protocol (IRB #16-F-13), and all subjects gave written informed consent. Asian Spine Journal Lumbar Spine in Supine versus Weight-Bearing MRI 3 2. Imaging protocol Scout images were obtained iso-centered at the L3L4 intervertebral disks after the participants were secured in the supine position on the MRI table. The height of the footrest was adjusted and recorded in the supine position before the table was slowly rotated to 87 vertical (as specified by the machine-operating protocol to prevent fall) to the ground, as the participants eased into a WB position with their feet shoulder-width apart. The participants were comfortably secured above the knee and at the pelvis using cushioned straps to help them maintain an upright position during imaging. All images were acquired using an open-field magnet (0.25 T) G Scan Brio WB MRI (Esaote S.p.A., Genova, Italy) in an upright position. Next, the participants were placed in the supine position by tilting the table back to the horizontal plane. They laid supine and rested for 5 minutes to relax their spine before the initiation of image acquisition in the supine position. Sagittal MR images of the lumbar spine (L1S1) were acquired in both positions using a fast spin-echo T2 sequence (TR=3,520 ms; TE=125 ms; number of acquisitions=1; matrix=288234; FOV=320320; oversampling=185%; slice thickness=4 mm; gap=1 mm; acquisition time=4 minutes 41 seconds). The scanning time and sequences we followed have been described in earlier studies reporting <5 minutes of scan time at each position [15]. Typically, each participant spent approximately 45 minutes per session, which included positioning, tilting, image acquisition, and resting time. The height of the standing platform, positions of the cushion straps, and the lumbar coil placements were measured for each participant to be replicated in the subsequent imaging sessions. 3. Image analysis All Digital Imaging and Communications in Medicine images were transferred to a proprietary image analysis platform (OrthoCAD; Esaote S.p.A.). The borders of the lumbar spine, first sacral vertebral bodies, spinal canal, and vertebral foramina were manually outlined on the image slices using the software. Images were then segmented and digitized using proprietary three-dimensional (3D) segmentation software (OrthoCAD) to quantify anatomical dimensions. The first author (N.K.M.) used semiautomated segmentation and measurement tools available in the software to quantify all dimensions presented in this Fig. 1. Mid-sagittal lumbar spine T2-weighted image showing the sacral angle, disc heights, and mid zonal spinal canal dimensions as demarcated by the proprietary software tool OrthoCAD. study (Fig. 1). Additionally, a single observer used ImageJ (National Institutes of Health, Bethesda, MD, USA; Imagej.nih.gov/ij/docs/faqs.html) to verify the linear dimensions measured in the images. 4. Measurement variables Linear dimensions (in millimeters) were measured as follows: Sagittal dimensions of the spinal canal were measured as the minimal available space at the vertebral junctional areas, referred to as zones (Fig. 1). Disk heights were measured in the mid-intervertebral spaces. Foraminal heights were measured at the narrowest portions along the intervertebral openings. All segmental and intersegmental angles (in degrees) were measured in the sagittal plane using the endplates superior to the concerned vertebrae. The foramen cross-sectional area (CSA) (in square millimeters) at each level was measured at the narrowest available point along image slices capturing the intervertebral foramen. Slice positions and imaging parameters in the protocol were kept consistent between the two sessions. 5. Statistical analysis Supine and WB measurements obtained from the two 4 Niladri Kumar Mahato et al. Asian Spine J 2024;18(1):1-11 sessions were tested separately for correlation using Pearsons correlation coefficient. Within-session differences between supine and WB images were tested for statistical significance using a two-tailed paired Student t-test. Considering potential changes in magnification and minor variability associated with participant positioning within the scanner in the two imaging sessions, the differences calculated between the supine and WB images were normalized for each session. This was performed by subtracting the supine measurements from the WB measurements and then dividing that value by the WB measurement (at each level) to obtain an absolute value for the dimension: [(Supine-WB)/WB]. Correlations between normalized differences between the two sessions were determined using Pearsons correlation coefficient. Additionally, factorial repeated measured analysis of variance (ANOVA) (without replication; 2 positions2 sessions), followed by multiple post-hoc comparisons (Tukeys test), was performed to determine the statistical significance of differences in each dimension across images between both positions and both imaging sessions. The intra-rater reliability of the measurements was evaluated by computing the intraclass correlation coefficients (ICC) of all measurement variables for the two sessions and two scanning positions (IBM SPSS Statistics for Windows, ver. 24.0; IBM Corp., Armonk, NY, USA). Results 1. Linear dimensions 1) Spinal canal dimensions Zones increased with WB (Fig. 2). Our findings showed that this increase was proportional to the initial dimensions measured across each zone in the supine position. We observed a strong correlation and intra-rater reliability for measurements acquired in the supine and WB positions (r=0.89 and 0.96, respectively) (Table 1). Furthermore, between-session normalized differences at the five zones were strongly correlated, indicating consistency in detecting supine versus WB changes (r=0.83). Additionally, differences in sagittal dimensions between the supine and WB positions were statistically significant in both sessions (F [3,59]=6.61; p<0.01). The spinal canal dimensions showed an increase at all levels from the supine position to the WB position. The change percentages observed were as follows: L1L2=11.35%, L2L3=10.18%, L3L4=3.21%, L4L5=8.93%, and L5S1=12.56%. 2) Disk heights Disk heights (mm) were reduced with WB (Fig. 2). Decreases in this dimension corresponded proportionally to the initial heights at each level in the supine position [15]. We detected a strong correlation and intra-rater reliability in the measurements acquired in the supine and WB positions (r=0.94 and 0.91, respectively) (Table 1). A moderate correlation was detected in the between-session normalized differences in disk heights at all five intervertebral Spinal canal thickness and disc height Supine Weight bearing 20 18 16 14 12 10 8 6 4 2 0 L1L2 L2L3 L3L4 L4L5 Spinal canal thickness L5S1 L1L2 L2L3 L3L4 L4L5 L5S1 Disc height Fig. 2. Spinal canal dimensions and disc heights (in millimeters) measured by supine and weight-bearing imaging. All parameters returned significant values when comparing the two imaging positions (p <0.05). Asian Spine Journal Lumbar Spine in Supine versus Weight-Bearing MRI 5 Table 1. Descriptive statistics of linear dimensions measured in images acquired with supine and WB positions in two separate sessions Zone Variable L1L2 L2L3 L3L4 L4L5 L5S1 r-value Spinal canal sagittal dimension Supine sessions (mm) 13.951.34 13.391.38 13.501.15 12.861.23 12.612.00 0.89 WB sessions (mm) 15.541.22 14.761.46 13.941.35 14.011.31 14.202.61 0.96 11.35 10.18 3.21 8.93 12.56 0.83 Supine sessions (mm) 11.172.13 11.631.30 13.441.74 14.433.10 12.971.71 0.94 WB sessions (mm) 10.111.42 11.261.57 12.841.62 13.812.66 12.142.31 0.91 9.50 3.20 4.44 4.41 6.40 0.64 Supine sessions (mm) 16.933.45 17.974.07 17.873.58 16.633.78 14.322.32 0.96 WB sessions (mm) 15.932.77 16.923.81 17.483.06 15.953.35 15.392.71 0.97 12.15 7.63 7.87 4.07 7.49 0.74 Supine sessions (mm) 16.663.48 17.194.22 18.865.05 13.894.29 14.493.41 0.96 WB sessions (mm) 14.632.36 15.883.11 17.383.51 15.682.66 14.72.21 0.97 5.88 5.86 2.18 5.93 2.47 0.79 a) % Changes Disc height a) % Changes Intervertebral foramen height Left % Changesa) Right a) % Changes Values are presented as meanstandard deviation or %. r-values indicate Pearsons correlation coefficients. Percentage changes denote measurement changes from the supine to the weight bearing positions. Percentage changes with indicate a decrease. WB, weight bearing. a) Supine vs. WB differences (normalized): normalized supine vs. WB difference for each session=(supineWB)/WB. levels, indicating consistency in detecting supine versus WB changes (r=0.64). Differences in disk heights between the supine and WB positions were statistically significant for both sessions (F [3,59]=23.34; p<0.01). The disk heights decreased at all levels from the supine position to the WB position. The change percentages observed were as follows: L1L2=9.50%, L2L3=3.20%, L3L4=4.44%, L4L5=4.41%, and L5S1=6.40%. 3) Foraminal heights Foraminal heights (mm) were bilaterally reduced with WB, except at the L5S1 junctions, where the foramina appeared to slightly enlarge. Analysis revealed a strong correlation and intra-rater reliability in the measurements acquired in the supine and WB positions bilaterally (r=0.96 and 0.97, respectively) (Table 1). The betweensession normalized differences in foraminal heights were strongly correlated at all five intervertebral levels, indicating consistency in detecting supine versus WB changes (right: r=0.79; left: r=0.74). The differences in foraminal heights between the supine and WB positions were sta- tistically significant in both sessions (F [3,59]=20.75; p<0.01). The intra-rater reliability of the measurements was 75% for each session and each scan position. All foraminal heights showed an increase at all levels, on both sides, from the supine position to the WB position, except for L5S1, which showed a decrease bilaterally. The change percentages observed on both sides were as follows: right: L1L2=12.15%, L2L3=7.63%, L3L4=7.87%, L4L5=4.07%, and L5S1=7.49%; left: L1L2=5.88%, L2L3=5.86%, L3L4=2.18%, L4L5=5.93%, and L5 S1=1.47%. 2. Angular dimensions: segmental angles Segmental angles increased with WB. In our findings, the angles increased caudally and were proportionate to the magnitude of the baseline angles measured in the supine position. However, the lumbosacral angle was reduced with WB (21.964.55 versus 20.794.99). Among the intersegmental angles, the lordosis (L1S1), sacral (horizontalS1), lumbar (L1L5), and lower lordosis (L3 6 Niladri Kumar Mahato et al. Asian Spine J 2024;18(1):1-11 70 Angular dimension Supine Weight bearing 60 50 40 30 20 10 0 L1L2 L2L3 L3L4 L4L5 L5S1 L3L4 angle L1L5 angle Sacral angle L1S1 angle Sehmental Inter-segmental Fig. 3. Segmental and inter-segmental angles (in degrees) measured by supine and weight-bearing imaging. All parameters returned significant values when comparing the two imaging positions (p <0.05). Table 2. Descriptive statistics of angular dimensions measured in images acquired in supine and WB positions in two separate sessions Segmental angles L1L2 Supine sessions () 3.331.24 WB sessions () 5.251.54 57.50 41.60 a) % Changes L2L3 L3L4 L4L5 L5S1 r -value 5.212.23 7.543.35 7.382.16 11.632.26 12.925.69 21.964.55 0.91 15.544.47 20.794.99 0.97 54.14 20.32 6.45 0.74 Values are presented as meanstandard deviation or %. r -values indicate Pearsons correlation coefficients. Percentage changes denote measurement changes from the supine to the weight bearing positions. Percentage changes with indicate a decrease. WB, weight bearing. a) Between-sessions differences (normalized): normalized supine vs. WB difference for each session=(supineWB)/WB. Table 3. Descriptive statistics of angular dimensions measured in images acquired in supine and WB positions in two separate sessions Inter-segmental angle Lordosis angle L1S1 Lumbar angle L1L5 Sacral angle horizontalS1 Lower lordosis angle L3L5 MeanSD r -value MeanSD r -value MeanSD r -value MeanSD r -value Supine sessions () 47.679.24 0.98 27.049.39 0.94 36.387.20 0.75 22.006.63 0.93 WB sessions () 56.337.67 0.94 38.585.42 0.88 37.678.51 0.78 27.255.46 0.76 23.86 0.84 39.29 0.54 6.07 0.61 18.18 0.68 a) % Changes r -values indicate Pearsons correlation coefficients. Percentage changes denote measurement changes from the supine to the weight bearing positions. Percentage changes with indicate a decrease. WB, weight bearing; SD, standard deviation. a) Supine vs. WB differences (normalized): normalized supine vs. WB difference for each session=(supineWB)/WB. L5) angles were the largest to the smallest in the supine position (Fig. 3). These angles increased with WB, with the highest increase observed in the lumbar angle (L1 L5) and the lowest increase observed in the sacral angle (horizontalS1) while standing. The measurements acquired in the supine and WB positions exhibited a strong correlation and intra-rater reliability (r=0.91 and 0.97, respectively) (Tables 2, 3). A moderately strong correlation was detected for normalized differences in between- session segmental angular data, indicating consistency in detecting supine versus WB alterations (r=0.74). Angular parameters were significantly different between the supine and WB positions in both sessions (F [3,59]=72.16; p<0.01). The intra-rater reliability of the measurements was 75% for each session and each scan position. All angular dimensions decreased at all levels from the supine position to the WB position, except for the L5 S1 intervertebral segmental angle, which increased. The Asian Spine Journal Lumbar Spine in Supine versus Weight-Bearing MRI 7 Foramen CSA Supine Weight bearing 160 140 120 100 80 60 40 20 0 L1L2 L2L3 L3L4 L4L5 L5S1 L1L2 L2L3 L3L4 L4L5 L5S1 Left Right Fig. 4. Intervertebral foramen cross-sectional areas (CSAs) measured by supine and weight-bearing imaging. All parameters returned significant values when comparing the two imaging positions (p <0.05). Table 4. Descriptive statistics of CSAs measured in images acquired in the supine and WB positions in two separate sessions L1L2 L2L3 L3L4 L4L5 L5S1 r -value 118.8719.79 114.0323.68 113.4915.54 116.1818.43 124.2516.16 0.87 109.2112.26 108.6019.25 108.5215.58 109.3316.60 125.2013.22 0.97 8.13 4.76 4.38 5.90 1.28 0.68 117.7015.64 112.4917.98 109.0315.18 110.73147.48 114.35129.32 0.92 110.7915.88 110.1312.21 111.3914.29 109.3615.88 122.2613.22 0.97 5.86 2.10 2.16 1.24 6.92 0.74 Inter-vertebral foramen CSA Left Supine sessions (mm2) 2 WB sessions (mm ) a) % Changes Right Supine sessions (mm2) 2 WB sessions (mm ) % Changesa) Values are presented as meanstandard deviation or %. r -values indicate Pearsons correlation coefficients. Percentage changes denote measurement changes from the supine to the weight bearing positions. Percentage changes with indicate a decrease. CSA, cross-sectional area; WB, weight bearing. a) Supine vs. WB differences (normalized): normalization of supine vs. WB difference for each session=(supineWB)/WB. change percentages observed were as follows: intervertebral segmental angles: L1L2=57.50%, L2L3=41.60%, L3L4=54.14%, L4L5=20.32%, L5S1=6.45%; L3L5 angle=23.86%; L1L5 angle=39.29%; sacral angle horizontalS1=6.07%; and L1S1 angle=18.18%. 3. Intervertebral foraminal CSA Foraminal CSAs (mm2) decreased with WB, except at the lumbosacral junction (L5S1), which consistently increased bilaterally (left: 124.8516.16 versus 125.2013.22; right: 114.35129.32 versus 122.2613.22, respectively) (Fig. 4). Increased CSA was also noted at the mid-lumbar level (L3L4) on the right side. A strong correlation and intra-rater reliability were observed in the CSAs acquired in the supine and WB positions (left: r=0.87 and 0.97; right: r=0.92 and 0.97, respectively) (Table 4). Furthermore, a strong correlation between the normalized differences from the two sessions was detected at all five levels, indicating consistency in measuring changes induced by WB (left: r=0.68; right: r=0.74). Foraminal CSAs significantly differed between the supine and WB positions in both sessions (F [3,59]=5.59; p<0.01). The intra-rater reliability of the measurements was 75% for each session and each scan position. The ICC showed high values of agreement for all dimensions (measured by sessions and scanning positions) calculated as inter-rater reliability using absolute agreement and a two-way random model 8 Niladri Kumar Mahato et al. Asian Spine J 2024;18(1):1-11 Table 5. ICC calculated for measured variables by sessions and by scanning positions Supine Variable WB ICC 95% CI ICC 95% CI Sagittal dimension 0.72 0.580.71 0.77 0.650.85 Disc heights 0.88 0.810.93 0.91 0.860.94 Left 0.94 0.910.96 0.94 0.910.96 Right 0.95 0.910.97 0.96 0.930.96 0.97 0.960.98 0.98 0.970.98 Left 0.92 0.870.95 0.83 0.740.90 Right 0.84 0.750.90 0.89 0.820.93 Linear dimensions Intervertebral foramen height Angular dimensions Intervertebral foramen CSA Inter-rater reliability was performed using absolute agreement and a two-way random model reporting single measures for ICC, in SPSS. ICC, intraclass correlation coefficients; WB, weight bearing; CI, confidence interval; CSA, cross-sectional area. (Table 5). All intervertebral foraminal CSAs increased at all levels, on both sides, from the supine position to the WB position, except for the L5S1 level, which decreased bilaterally. The change percentages observed on both sides were as follows: right: L1L2=8.13%, L2L3=4.76%, L3L4=4.38%, L4L5=5.90%, L5S1=0.28%; left: L1 L2=5.86%, L2L3=2.10%, L3L4=2.16%, L4L5=1.24%, and L5S1=6.92%. Only one pairwise Tukey honestly significant difference comparison (i.e., foraminal height) between the supine and WB positions was significant (p<0.01); all other comparisons were insignificant. This result is expected considering that the pairs of the compared segmental means (two supine and two WB) remained clustered together. All positional comparisons tested (and presented) returned significant p-values (p<0.05) when assessed using paired Student t -test; this result was supported by the significant ANOVA F statistic, as reported above. Discussion This study assessed (1) specific dimensions that demonstrated morphometric shifts between the two positions of imaging, (2) the reliability of measurements on lumbar spine images between two loading positions and across two imaging sessions, and (3) the statistical significance of the anatomical changes observed between the supine and WB positions. Increases in the sagittal dimensions observed at the vertebral junctional zones within the spinal canal may have occurred because of dynamic alterations in intra- and intersegmental changes in the vertebral angles, increased apposition of the zygapophyseal joints, and bulging of the interlaminar ligament system with WB, as reported in the literature [16,17]. Such dynamic effects on the lumbar spinal canal with axially loaded spine observed with computed tomographymyelography and MRI in patients with sciatica have been reported and agree to the findings of this study involving asymptomatic individuals [6,11]. These increments could also reflect increasing curvature of the lumbar spine, particularly at the thoracolumbar and lumbosacral junctions with the upright spine [18-21]. Reductions in disk heights reflect axial loading, though the reductions are not proportionately as large as reported in some earlier studies [22-24]. In this study, disk heights were measured at the mid-intervertebral spaces to detect changes at the level of the centrally placed nucleus. With upright WB, compression of the peripheral annulus may stabilize or even increase the height of the centrally located disk nucleus. Disk heights were reduced at the L1 L2 junction. Additionally, although earlier studies have reported Modic I changes to increase in size from the supine position to the standing position with MRI studies that correlated with an increase in pain intensity in the standing position, this study further substantiates the evidence that WB may uncover the biomechanical stress and active discopathy theories in LBP, as suggested by the authors [15]. Intervertebral foraminal heights decreased upon standing, possibly due to compressive loading at the posterior vertebral elements from the accentuation of the overall lumbar curvature, reduction of peripheral disk heights, or increased anterior angulation at segmental endplates [19]. This aligns with the observation that forward flexion facilitates foraminal widening by reducing posterior element stress, increasing the vertical dimension of the foramen [22-24]. Accordingly, forward flexion of the lumbar spine often mechanically reduces pain resulting from foraminal and spinal canal narrowing [25-27]. Interestingly, the L5 S1 foramina marginally increased in this dimension on WB, possibly due to a greater increase in the sacral angle upon standing. The relatively coronal orientation of the facet joints at this level may serve as struts that not only prevented the L5 listhesis at this junction but also acted as Asian Spine Journal a fulcrum to help increase the L5S1 angle, thereby opening up the foramen dimensions [20-22]. Interestingly, some studies have reported comparable changes in the intervertebral foraminal spaces as effects of axially loaded MRI of the lumbar spine on dural sac and lateral recesses [16]. All segmental and intersegmental angles in the sagittal plane increased with different magnitudes with WB. However, the overall L5S1 angle slightly decreased (with greater variance). Nonetheless, all other angles related to the S1 endplate, including the lordosis and sacral angles, significantly increased with the upright position [23,24]. Further investigation is required to detect whether lumbar spine curvature variability is associated with overall changes in the spinal canal or intervertebral foraminal dimensions in individuals with back pain upon WB [25]. Interestingly, foraminal CSAs demonstrated changes due to alterations in disk and foraminal heights on WB. However, the lumbosacral foramina marginally increased bilaterally in CSA on WB. Thus, unlike the rest of the cranially located foramina, the L5S1 foramina widened on standing, with a concomitant increase in CSA and height. Intuitively, one may assume that although the vertical foraminal heights reduce on WB, the available anteroposterior space in these foramina may increase, thereby preventing critical narrowing of the passage [26]. However, this study indicates that the corresponding CSAs at the L1L4 foramina also decrease with standing. Notwithstanding, the lumbar intervertebral foramina are tubular spaces that are directed somewhat posterolaterally (not strictly in the coronal plane). Therefore, any change in the dimension perpendicular to the plane of the sagittal image may remain undetected and could prevent the detection of an increase in the foraminal dimension in that plane [27]. The CSA at the lumbosacral (L5S1) foramen marginally increased bilaterally, as did its vertical dimensions. This increase may be due to the significant angular increases associated with the S1 endplate on WB. Because narrowing of the foramina is pathologically related to nerve compression and sciatica, changes in all foraminal CSAs on WB could yield clinically valuable information [25,28]. This study has some limitations. First, none of the study participants had chronic or acute back pain episodes, and all individuals were within a specific BMI range. Thus, we assume that the observed anatomical changes were within physiological limits and represent the ef- Lumbar Spine in Supine versus Weight-Bearing MRI 9 fects of normal WB in the upright position. Second, the disk hydration status was not objectively accounted for every imaging session in terms of its potential effects on the disk height measurements. The disk height changes reported in this study were discussed as changes that incurred with gravitational load bearing only. Some changes related to disk hydration may have impacted the variability of data reported in this study. Lastly, although the scan time in the upright position was kept to the minimal mainly to acquire sagittal images and very few axial images for comparison, shortening the scan time further in the protocol may help include participants with back pain in such studies in the future. Comparisons could also be improved by generating a 3D rendition of the images and measuring additional parameters in multiaxial planes. Examining specific anatomical dimensions that change in the WB position could be critical in identifying specific structural causes of LBP and lumbar instability, for example, markers that may remain undetected on supine MRI [23]. Despite the relatively lower sample size, the number of images examined could delineate (normality of distributions, statistical significance within the assigned alpha levels) differences in the anatomical parameters measured in the study. Images acquired from the relatively low-strength 0.25T MRI machine could provide adequate resolution to allow accurate and consistent measurements. The equipment is approved for clinical usage and comes with validated measurement software for use in clinical research and practice. Measurements of the anatomical changes presented in this study may help contextualize the importance of WB MRI in detecting potential anatomical changes that may be etiologically associated with back pain and spine instability. These changes may otherwise remain undetected with routine supine imaging. Though longer MRI protocols may be challenging for individuals with concurrent back pain, WB imaging could still be useful in detecting diagnostically valuable anatomical changes in the lumbar spine where indicated [29,30]. Conclusions WB imaging may improve detection of changes in the lumbar spine anatomy compared with supine MRI. As a future step, findings from this study could be further corroborated in individuals with back pain to assess the validity of assessment in the context of specific dimen- 10 Niladri Kumar Mahato et al. sions (concerning spinal canal, disks, and intervertebral foramina) that may be pathologically related to back pain. Conflict of Interest No potential conflict of interest relevant to this article was reported. ORCID Niladri Kumar Mahato: https://orcid.org/0000-0001-54391172; Paramanand Maharaj: https://orcid.org/0000-00031859-1606; Brian C. Clark: https://orcid.org/0000-00026021-6431 Author Contributions Conceptualization: NKM, BCC; data curation: NKM, BCC; formal analysis: NKM, BCC; funding acquisition: NA; methodology: NKM, BCC, PM; project administration: BCC, NKM; visualization: NKM; writingoriginal draft: NKM, BCC; writingreview & editing: NKM, BCC, PM; final approval of the manuscript: all authors. References 1. Weishaupt D, Schmid MR, Zanetti M, et al. 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... Article https://doi.org/10.1038/s41467-023-43012-9 Conserved chromatin and repetitive patterns reveal slow genome evolution in frogs Received: 28 October 2021 Accepted: 27 October 2023 1234567890():,; 1234567890():,; Check for updates Jessen V. Bredeson 1,2,19, Austin B. Mudd1,19, Soa Medina-Ruiz1,19, Therese Mitros1, Owen Kabnick Smith 3, Kelly E. Miller1, Jessica B. Lyons 1, Sanjit S. Batra4, Joseph Park1, Kodiak C. Berkoff 1, Christopher Plott 5, Jane Grimwood 5, Jeremy Schmutz 5, Guadalupe Aguirre-Figueroa3, Mustafa K. Khokha 6, Maura Lane6, Isabelle Philipp1, Mara Laslo 7, James Hanken 7, Gwenneg Kerdivel8, Nicolas Buisine8, Laurent M. Sachs 8, Daniel R. Buchholz9, Taejoon Kwon 10,11, Heidi Smith-Parker 12, Marcos Gridi-Papp 13, Michael J. Ryan12, Robert D. Denton14, John H. Malone 14, John B. Wallingford15, Aaron F. Straight 3, Rebecca Heald 1, Dirk Hockemeyer 1,16,17, Richard M. Harland 1 & Daniel S. Rokhsar 1,2,16,17,18 Frogs are an ecologically diverse and phylogenetically ancient group of anuran amphibians that include important vertebrate cell and developmental model systems, notably the genus Xenopus. Here we report a high-quality reference genome sequence for the western clawed frog, Xenopus tropicalis, along with draft chromosome-scale sequences of three distantly related emerging model frog species, Eleutherodactylus coqui, Engystomops pustulosus, and Hymenochirus boettgeri. Frog chromosomes have remained remarkably stable since the Mesozoic Era, with limited Robertsonian (i.e., arm-preserving) translocations and end-to-end fusions found among the smaller chromosomes. Conservation of synteny includes conservation of centromere locations, marked by centromeric tandem repeats associated with Cenp-a binding surrounded by pericentromeric LINE/L1 elements. This work explores the structure of chromosomes across frogs, using a dense meiotic linkage map for X. tropicalis and chromatin conformation capture (Hi-C) data for all species. Abundant satellite repeats occupy the unusually long (~20 megabase) terminal regions of each chromosome that coincide with high rates of recombination. Both embryonic and differentiated cells show reproducible associations of centromeric chromatin and of telomeres, reecting a Rabl-like conguration. Our comparative analyses reveal 13 conserved ancestral anuran chromosomes from which contemporary frog genomes were constructed. Amphibians are widely used models in developmental and cell biology15, and their importance extends to the elds of infectious disease, ecology, pharmacology, environmental health, and biological diversity610. While the principal model systems belong to the genus A full list of afliations appears at the end of the paper. Nature Communications | (2024)15:579 Xenopus (notably the diploid western clawed frog X. tropicalis and the paleo-allotetraploid African clawed frog X. laevis), other amphibian models have increasingly been introduced due to their diverse developmental, cell biological, physiological, and behavioral adaptations1121. e-mail: dsrokhsar@gmail.com 1 Article While genome evolution has been extensively studied in mammals22 and birds23,24, the relative lack of phylogenetically diverse chromosome-scale frog genomes has limited the study of genome evolution in anuran amphibians. Here, we report a high-quality assembly for X. tropicalis and three new chromosome-scale genome assemblies for the Puerto Rican coqu (Eleutherodactylus coqui), a direct-developing frog without a tadpole stage16,19, the tngara frog (Engystomops pustulosus), which is a model for vocalization and mate choice15,18,20, and the Zaire dwarf clawed frog (Hymenochirus boettgeri), which has an unusually small embryo, is a model for regulation of cell and body sizes, and a source of potent host-defense peptides with therapeutic potential13,17,21. Genome assemblies are essential resources for further work to exploit the experimental possibilities of these diverse animals. The new high-quality X. tropicalis genome upgrades previous draft assemblies25,26 and our new genomes complement draft chromosome-scale sequences for the African clawed frog27 (Xenopus laevis), the African bullfrog28 (Pyxicephalus adspersus), the Leishan moustache toad29 (Leptobrachium leishanense), the Ailao moustache toad30 (Leptobrachium [Vibrissaphora] ailaonicum), and Asiatic toad31 (Bufo gargarizans), as well as scaffold- and contig-scale assemblies for other species32. The rapidly increasing number of chromosome-scale genome assemblies makes anurans ripe for comparative genomic and evolutionary analysis. Chromosome number variation among frogs is limited3335. Based on cytological36,37 and sequence comparisons25,27,33,38,39 most frogs have n ~1012 pairs of chromosomes. A recent meiotic map of the yellowbellied toad Bombina variegata showed that its twelve chromosomes are simply related to the ten chromosomes of X. tropicalis40. The stability of the frog karyotype contrasts with the more dramatic variation seen across mammals22,37,41,42, which as a group is considerably younger than frogs. The constancy of the frog karyotype parallels the static karyotypes of birds23,43, although birds typically have nearly three times more chromosomes than frogs, including numerous microchromosomes (among frogs, only the basal Ascaphus44 has microchromosomes). Despite the stable frog chromosome number, however, fusions, ssions, and other interchromosomal rearrangements do occur, and we can use comparisons among chromosomescale genome sequences to (1) infer the ancestral chromosomal elements, (2) determine the rearrangements that have occurred during frog phylogeny, and (3) characterize the patterns of chromosomal change among frogs. These ndings of conserved synteny among frogs are consistent with prior demonstrations of conservation between Xenopus tropicalis with other tetrapods, including human and chicken25,45. Since frog karyotypes are so highly conserved, X. tropicalis can be used as a model for studying chromosome structure40, chromatin interaction, and recombination for the entire clade. Features that can be illuminated at the sequence level include the structure and organization of centromeres and the nature of the unusually long subtelomeres relative to mammals (frog subtelomeres are ~20 megabases, compared with the mammalian subtelomeres that are typically shorter than a megabase). The extended subtelomeres of frogs form interacting chromatin structures in interphase nuclei that reect threedimensional intra-chromosome and inter-chromosome subtelomeric contacts, which are consistent with a Rabl-like conguration. As in other animals, subtelomeres of frogs have an elevated GC content and recombination rate. Here we show that the unusually high enrichment of recombination in the subtelomeres likely reects similar structural and functional properties in other vertebrates, though the quality of the assembly reveals that the length of subtelomeres, expansion of microsatellite repeat sequences by unequal crossing over, and high recombination rates are considerably greater in frogs than in mammals. A strong correlation between recombination rate and microsatellite sequences suggests that unequal crossing over during meiotic recombination is implicated in the expansion of satellites in the Nature Communications | (2024)15:579 https://doi.org/10.1038/s41467-023-43012-9 subtelomeres. We use Cenp-a binding at satellites to conrm centromere identity and extend the predictive power of the repeat structures to centromeres of other frogs. We address the unusually high recombination rate in subtelomeric regions, correlating with the landscape of base composition and transposons. Over the 200 million years (My) of evolution that we address here, centromeres have generally been stable, but the few karyotypic changes reveal the predominant Robertsonian translocations at centromeric regions; we also document the slow degeneration that occurs to inactivated centromeres and fused telomeres, changes that are obscured in animals with rapidly evolving karyotypes. Results and discussion High-quality chromosome-scale genome assembly for X. tropicalis To study the structure and organization of Xenopus tropicalis chromosomes and facilitate comparisons with other frog genomes, we assembled a high-quality chromosomal reference genome sequence (Supplementary Data 1, Supplementary Fig. 1, and Supplementary Notes 1 and 2) by integrating data from multiple sequencing technologies, including Single-Molecule Real-Time long reads (SMRT sequencing; Pacic Biosciences), linked-read sets (10x Genomics), short-read shotgun sequencing, in vivo chromatin conformation capture, and meiotic mapping, combined with previously generated dideoxy shotgun sequence. New sequences were generated from 17thgeneration individuals from the same inbred Nigerian line that was used in the original Sanger shotgun sequencing45. The new reference assembly, version 10 (v10), spans 1448.4 megabases (Mb) and is substantially more complete than the previous (v9) sequence25, assigning 219.2 Mb more sequence to chromosomes (Supplementary Table 1). The v10 assembly is also far more contiguous, with half of the sequence contained in 32 contigs longer than 14.6 Mb (in comparison, this N50-length was. 71.0 kilobases [kb] in v9). The assembly captures 99.6% of known coding sequences (Supplementary Table 2 and Supplementary Note 2). We found that the fragmented quality of earlier assemblies was due, in part, to the fact that 68.3 Mb (4.71%) of the genome was not sampled by the 8 redundant Sanger dideoxy whole-genome shotgun dataset45 (Supplementary Fig. 2ac and Supplementary Note 2). These missing sequences are apparently due to non-uniformities in shotgun cloning and/or sequencing (Supplementary Fig. 2df). Previously absent sequences are distributed across 140.5k blocks of mean size 485.7 basepairs (bp) (longest 50.0 kb) on the new reference assembly, are enriched for sequences with high GC content (Supplementary Fig. 2g), and capture an additional 6774 protein-coding exons from among 4718 CDS sequences (Supplementary Fig. 2d, e). The enhanced contiguity of v10 is accounted for by the relatively uniform coverage of PacBio long-read sequences along the genome, as expected from other studies4649. Most remaining gaps are in highly repetitive and satellite-rich centromeres and subtelomeric regions (see below) (Supplementary Fig. 2a). Additional chromosome-scale frog genomes To assess the evolution of chromosome structure across a diverse set of frogs, we generated chromosome-scale genome assemblies for three new emerging model species, including the Zaire dwarf clawed frog Hymenochirus boettgeri (a member of the family Pipidae along with Xenopus spp.), and two neobratrachians: the Puerto Rican coqu Eleutherodactylus coqui (family Eleutherodactylidae) and the tngara frog Engystomops pustulosus (family Leptodactylidae). These chromosome-scale draft genomes were primarily assembled from short-read datasets and chromatin conformation capture (Hi-C) data (Supplementary Data 1, Supplementary Table 3, and Supplementary Note 3). To further expand the scope of our comparisons, we also updated the assemblies of two recently published frog genomes: the 2 Article African bullfrog Pyxicephalus adspersus28, from the neobatrachian family Pyxicephalidae, and the Ailao moustache toad Leptobrachium (Vibrissaphora) ailaonicum29, from the family Megophryidae (Supplementary Fig. 3 and Supplementary Note 3). These species span the pipanuran clade, which comprises all extant frogs except for a small number of phylogenetically basal taxa, such as Bombina40 and Ascaphus50. The chromosome numbers of the new assemblies agree with previously described karyotypes for E. coqui51 (2n = 26) and E. pustulosus52 (2n = 22). The literature for H. boettgeri, however, is more equivocal, with reports53,54 of 2n = 2024. The n = 9 chromosomes of our H. boettgeri assembly are consistent with our chromosome spreads (Supplementary Fig. 3a). The karyotype variability in the published literature and discrepancy with the karyotypes of our H. boettgeri samples may be the result of cryptic sub-populations within this species or segregating chromosome polymorphisms. Protein-coding gene set for X. tropicalis The improved X. tropicalis genome encodes an estimated 25,016 protein-coding genes (Supplementary Table 4), which we predicted by taking advantage of 8580 full-length-insert X. tropicalis cDNAs from the Mammalian Gene Collection55 (MGC), 1.27 million Sangersequenced expressed sequence tags45 (ESTs), and 334.5 gigabases (Gb) of RNA-seq data from an aggregate of 16 conditions and tissues56,57 (Supplementary Data 1 and Supplementary Note 2). The predicted gene set is a notable improvement on previous annotations, both in completeness and in full-length gene-level accuracy, due in part to the more complete and contiguous assembly (Supplementary Fig. 1, Supplementary Table 2, and Supplementary Note 2). In particular, singlemolecule long reads lled gaps in the previous X. tropicalis genome assemblies that likely arose from cloning biases in the Sanger sequencing process, encompassing exons embedded in highly repetitive sequences (Supplementary Fig. 2). A measure of this completeness and the utility of the X. tropicalis genome is provided by comparing its gene set with those of vertebrate model systems with reference-quality genomes, including chicken58, zebrash59, mouse60, and human61,62 (Supplementary Fig. 4ac). Notably, despite the closer phylogenetic relationship between birds and mammals, X. tropicalis shares more orthologous gene families (and mutual best hits) with human than does chicken, possibly because of the loss of genomic segments in the bird lineage23,63 and/or residual incompleteness of the chicken reference sequence, due to the absence of several microchromosomes58. For example, of 13,008 vertebrate gene families with representation from at least four of the vertebrate reference species, only 341 are missing from X. tropicalis versus 1110 from chicken (Supplementary Fig. 4a). The current X. tropicalis genome assembly also resolves gene order and completeness of gene structures in the long subtelomeres that were missed in previous assemblies due to their highly repetitive nature (Supplementary Fig. 2). Protein-coding gene sets for additional frogs We annotated the new genomes of E. coqui, E. pustulosus, H. boettgeri, and P. adspersus using transcriptome data from these species (Supplementary Data 1) and peptide homology with X. tropicalis (Supplementary Tables 5 and 6). To include mustache toad in our cross-frog comparisons, we adopted the published annotation from ref. 29 (Supplementary Note 3). We found 14,412 orthologous groups across the ve genera with OrthoVenn264, including genes found in at least four of the ve frog genera represented (Supplementary Fig. 4d). As expected, due to its reference-quality genome and well-studied transcriptome, only 72 of these clusters were not represented in X. tropicalis (and only 42 clusters from gene families present in six or more members among a larger set of seven frog species, see Supplementary Fig. 4e); the additional frog genomes each had between 575 and 712 of these genes missing (or mis-clustered), suggesting better than 95% Nature Communications | (2024)15:579 https://doi.org/10.1038/s41467-023-43012-9 completeness in the other species. For analyses of synteny, we further restricted our attention to 7292 one-to-one gene orthologs that were present on chromosomes (as opposed to unlinked scaffolds) in the core genomes X. tropicalis, H. boettgeri, E. coqui, E. pustulosus, and P. adspersus. The total branch length in the pipanuran tree shown in Fig. 1 (including both X. laevis subgenomes) is 2.58 substitutions per fourfold synonymous site. Repetitive landscape Centromeric and telomeric tandem repeats play a critical role in the stability of chromosome structure65. Nonetheless, other kinds of repeats also play a role in the preservation of these important chromosome landmarks66, 67. The new X. tropicalis v10 assembly captures sequences from centromeres and distal subtelomeres that were fragmented in the previous assemblies25,45. The percentage of the genome covered by transposable elements is slightly higher than previously reported45 (36.82% vs. 34%) (Supplementary Table 7). Insertional bias in the pericentromeric regions is observed for specic families of long interspersed elements (LINEs), including the relatively young Chicken Repeat 1 (CR1)68 (3.14% of the genome) and the ancient L1 (1.06%) (Fig. 2 and Supplementary Fig. 5). The X. tropicalis v10 assembly captures signicantly more tandem repeats in the distal subtelomeric portions of the genome relative to earlier assemblies. An exhaustive search for tandem repeats using Tandem Repeats Finder69 determined that 10.67% of the chromosomes are covered by tandem arrays consisting of 5 or more monomeric units greater than 10 bp. Many tandem repeat footprints lie in the gaps of previous assemblies25,45 (Supplementary Fig. 2). Our new hybrid genome assembly closed many gaps containing centromeric and subtelomeric tandem repeats, and captured numerous subtelomeric genes (Supplementary Fig. 2). The overall repeat landscape derived from the X. tropicalis assembly is mirrored in the other frog assemblies, with similar centromeric repeats, and lengthy subtelomeres, as discussed below. Genetic variation The inbred X. tropicalis reference genotype was nominally derived from 17 generations of brother-sister mating, starting with two Nigerian founders. In the absence of selection, this process should lead to an increasingly homozygous genome due to increasing identity by descent of the two reference haplotypes, with residual heterozygosity conned to short blocks totaling a fraction ~1.17 (0.809)t of the genetic map70, or 3.2% after t = 17 generations of full-sib mating. In contrast, we observe that 11.7% of the genome (125.12 cM out of a total of 1070.16 cM) exhibits residual heterozygosity (Supplementary Fig. 6). While this excess could be explained by balancing selection due to recessive lethals, a more mundane possibility is that some non-fullsib mating occurred during the inbreeding process. Errors early in the inbreeding process would be consistent with the unexpectedly high heterozygosity (~44%) observed in two 13th-generation members of the lineage (Supplementary Fig. 6), which far exceeds the 7.4% theoretical expectation from repeated full-sib mating. The approximately fourfold further reduction from these individuals to our 17thgeneration reference, however, is consistent with theoretical expectations in the absence of selection. Residual blocks of heterozygosity after inbreeding reect distinct founder haplotypes. Within these blocks, we observe 3.0 singlenucleotide variants per kilobase, which serves as an estimate of the heterozygosity of the wild Nigerian population. To begin to develop a catalog of segregating variation in X. tropicalis, we also shotgunsequenced pools of frogs from the Nigerian and Ivory Coast B populations, which are the two main sources of experimental animals. These two populations have been previously analyzed using SSLP markers71. From our light pool shotgun analysis, we identied a total of 6,546,379 SNPs, including 2,482,703 variants in the Nigerian pool and 4,661,928 3 Article https://doi.org/10.1038/s41467-023-43012-9 2n = 26 2n = 26 2n = 22 2n = 26 2n = 26 2n = 26 2n = 26 2n = 26 2n = 18 2n = 20 2n = 20 2n = 20 2n = 18 2n = 18 Mya 2n = 18 Fig. 1 | Phylogenetic tree and gene ortholog alignment. The phylogenetic tree of the seven analyzed species, calculated from fourfold degenerate sites and divergence time condence intervals, drawn with FigTree (commit 901211e, https:// github.com/rambaut/gtree): Xenopus tropicalis, X. laevis, and Hymenochirus boettgeri (Pipoidea: Pipidae); Leptobrachium (Vibrissaphora) ailaonicum (Pelobatoidea: Megaphrynidae); Engystomops pustulosus (Neobatrachia [Hyloidea]: Leptodactylidae), Eleutherodactylus coqui (Neobatrachia [Hyloidea]: Euleutherodactylidae); and Pyxicephalus adspersus (Neobatrachia [Ranoidea]: Pyxicephalidae). The ancestral karyotype is labeled at each node on the tree. Black circles with white text refer to chromosome changes summarized in Table 1. The alignment plot was generated with JCVI using the 7292 described chromosome one- to-one gene orthologs from OrthoVenn2, followed by manual ltering of single stray orthologs. The Hi-C-derived centromere position is represented with a black circle on each chromosome. Ancestral chromosomes (A to M) are labeled at the top of the alignment based on the corresponding region in P. adspersus. The alignments for each ancestral chromosome are colored uniquely, with those upstream and downstream of the X. tropicalis centromeric satellite repeat colored in dark and light shades of the ancestral chromosome color. Chromosomes labeled with asterisks are shown reverse complemented relative to their orientations in the genome assembly. Mya millions of years ago, n the haploid chromosome number. Source data are provided as a Source Data le. in the Ivory Coast B pool, with 598,252 shared by both pools, suggesting differentiation between populations (Supplementary Fig. 6 and Supplementary Note 2). At least some of these pipanuran elements have a deeper ancestry within amphibians. For example, the chromosomes of the discoglossid frog Bombina variegata (n = 12), an outgroup to the pipanurans, show considerable conservation of synteny with X. tropicalis based on linkage mapping40. Compared with the pipanuran ancestral elements described here, the nine B. variegata chromosomes 2, 3, 4, 5, 6, 8, 9, 10, and 12 correspond to nine pipanuran elements A, B, C, F, G, H, I, E, and J, respectively, extending these syntenic elements to the last common ancestor of Bombina+pipanurans (which does not have a common name). The remaining three B. variegata chromosomes 1, 7, and 11 are combinations of the remaining four pipanuran elements D, K, L, and M. Similarly, the genome of the axolotl, Ambystoma mexicanum, a member of the order Caudata (salamanders and newts) and ~292 million years divergent from pipanurans74, also conserves multiple syntenic units with pipanurans (Supplementary Fig. 7i). For example, axolotl chromosomes 4, 6, 7, and 14 are in near 1:1 correspondence with pipanuran elements F, A, B, and K, respectively, although small pieces of F and A can be found on axolotl 10, and parts of B can be found on axolotl 9 and 13. Other axolotl chromosomes are fusions of parts of two or more pipanuran elements. For example, axolotl chromosome 5 is a fusion of a portion of J with most of G; the remainder of G is fused with a portion of L on the q arm of axolotl chromosome 2. Further Conserved synteny and ancestral chromosomes Comparison of the chromosomal positions of orthologs across seven frog genomes reveals extensive conservation of synteny and collinearity (Fig. 1 and Supplementary Fig. 7ag). We identied 13 conserved pipanuran syntenic units that we denote A through M (Methods and Supplementary Note 4). Each unit likely represents an ancestral pipanuran chromosome, an observation consistent with the 2n = 26 ancestral karyotype inferred from cytogenetic comparisons across frogs36,72. Over 95% (6952 of 7292) of chromosomal one-to-one gene orthologs are maintained in the same unit across the ve frog species, attesting to the stability of these chromosomal elements (Fig. 1). The conservation of gene content per element is comparable to the 95% ortholog maintenance in the Muller elements in Drosophila spp73. Despite an over twofold difference in total genome size across the sampled genomes, each ancestral pipanuran element accounts for a nearly constant proportion of the total genome size, gene count, and repeat count in each species, implying uniform expansions and contractions during the history of the clade (Supplementary Fig. 7h). Nature Communications | (2024)15:579 4 https://doi.org/10.1038/s41467-023-43012-9 Repeat enrichment 150 75 5.4 2.7 Rec. Rate kb/Mb Article Chr1 Chr2 Chr3 Chr4 Chr5 Chr6 Chr7 Chr8 Chr9 Chr10 Fig. 2 | Density of pericentromeric and subtelomeric repeats in Xenopus tropicalis. Pericentromeric (red) and subtelomeric (purple) regions were used to obtain enriched repeats, excluding chromosomes with short p-arms (chromosomes 3, 8, and 10). Pericentromeric repeats (yellow) correspond to selected subsets of non-LTR retrotransposons (CR1, L1, and Penelope), LTR retrotransposons (Ty3), and DNA transposons (PiggyBac and Harbinger). Subtelomere- enriched repeats (blue) correspond mainly to satellite repeats and LTR retrotransposons (Ty3, Ngaro). Densities of each repeat type plotted as kb/Mb. Chromosomes are centered by the position of centromeric tandem repeats (black dots). Rates of recombination (Rec. rate) in cM/Mb are shown as solid black lines. Tick marks indicate 10 Mb blocks (Supplementary Fig. 5). kb kilobases, Mb megabases, cM centiMorgans. Source data are provided as a Source Data le. comparisons are needed to determine which of these rearrangements occurred on the axolotl vs. the stem pipanuran lineage. Genomes from the superfamilies Leiopelmatoidea and Alytoidea, which diverged prior to the radiation of pipanurans, will also be informative. Chromosomal conserved synteny across pipanuran frogs is comparable to that observed in birds, which have evolved by limited intra-chromosomal rearrangement from an n = 40 ancestor43, mostly involving fusion of microchromosomes, as we nd here for pipanurans (see below). The relative stasis of frog and bird chromosomes is in contrast to the variable karyotypes of mammals, which was rst noted by Bush et al.37 and is now extensively documented at the level of chromosomal painting22 and genome sequence42. The reasons for these different modes of evolution remain unclear but are likely related to the difculty in xing partial-arm chromosomal rearrangements in large historically panmictic populations due to reduced fertility in translocation heterozygotes, as rst noted by Wright75. Partial-arm rearrangements, as observed in mammals, can become xed in populations that are dynamically subdivided by local extinction and colonization, which allows the reduced fertility of translocation heterozygotes to be overcome by genetic drift76. Robertsonian or centric translocations involving breaks and joins near centromeres account for several of the rare rearrangements (Figs. 1 and 3b). For example, element G clearly experienced centric ssion in the E. coqui lineage. Conversely, I and M underwent centric fusion in the E. pustulosus lineage. E. coqui has experienced the most intense rearrangement, including Robertsonian ssions of A and G, a Robertsonian fusion of I/K, and a signicant series of Robertsonian rearrangements involving B, E, F, and H that resulted in Bprox/H, Bdist/ Fdist, and E/Fprox (Table 1 and Supplementary Table 8). (Mechanistically, these ssions and fusions likely occur by translocations; see ref. 77 for a discussion.) Elements I and H form the two arms of a submetacentric chromosome in pipids (Fig. 3a), and therefore the pipid ancestor, but are found as either independent acrocentric chromosomes (e.g., in P. adspersus and L. ailaonicum) or as arms of Table 1 | Organization and conservation of the 13 ancestral chromosomes of pipanuran genomes Phylogenetic position Structural event (1) Stem pipid lineage J + K JK D. + E. D.E Chromosome evolution Block rearrangements of the 13 ancestral elements dominate the evolutionary dynamics of pipanuran karyotypes (Table 1 and Fig. 1). While element C has remained intact as a single chromosome across the group (except for internal inversions), all of the other elements have experienced translocations during pipanuran evolution. During these translocations, the elements have remained intact except for the breakage of elements A and M by reciprocal partial-arm exchange observed in P. adspersus chromosomes 3 and 6. To trace the evolutionary history of centromeres shown in Fig. 1, we inferred their positions using Hi-C contact map patterns, as in X. tropicalis (where centromeres were also conrmed by analysis of Cenp-a binding as described below). In general, the pericentromeres of other pipanurans were characterized by the same repetitive element families found in Xenopus, further corroborating their identication. Overall, we found broad pericentromeric conservation among the species analyzed (Figs. 1 and 3a). Nature Communications | (2024)15:579 I + H I H (Rob. fusion) (2) P. adspersus lineage after divergence from R. temporaria (3) E. pustulosus lineage after divergence from E. coqui (4) E. coqui lineage after divergence from E. pustulosus A + M A1.m1 + m2.A2 M + I M.I (Rob) K + D K.D (Possible end-end) G1 G2 G1 + G2 (Rob. ssion) A1 A2 A1 + A2 (Rob. ssion) I + K I K (Rob. fusion + inversion) E + F1F2 + B1B2 + H EF1 + F2B2 + B1H (5) H. boettgeri lineage after divergence from Xenopus M + JK MJK (6) X. laevis progenitor lineage after divergence from X. tropicalis L + M LM Rob Robertsonian. Middle-dots (i.e., ) represent centromeres. Periods (i.e., .) represent translocation breakpoints. 5 Article https://doi.org/10.1038/s41467-023-43012-9 a Hbo 7 0 Xtr 7 0 10 Xla 7L 0 10 Epu 1 0 Xtr 1 0 Eco 7 0 20 40 Lai 10 0 20 40 Xtr 4 0 20 40 60 20 30 20 80 40 30 100 50 40 50 120 60 140 70 60 80 70 160 180 200 90 100 110 80 90 100 220 120 110 240 130 120 b 20 40 60 20 40 60 80 100 120 140 160 180 200 220 240 260 280 300 320 60 80 100 120 Eco 3 80 100 120 0 140 20 160 180 200 40 60 80 100 120 140 160 40 60 80 100 120 140 160 c Pad 9 10 60 60 20 40 Lai 8 0 80 100 120 30 20 40 50 60 0 70 80 20 90 100 Pad 8 0 110 120 20 130 40 140 150 60 Fig. 3 | Subtelomeric repeats highlight regions of chromosome fusion. Examples of (a) conserved structure and pericentromere maintenance of H. boettgeri (Hbo), X. tropicalis (Xtr), and X. laevis (Xla) chromosomes; b a Robertsonian translocation in the lineage leading to E. coqui (Eco), shown compared with E. pustulosus (Epu) and X. tropicalis; and c an end-to-end fusion that occurred in the lineage giving rise to X. tropicalis and subsequent pericentromere loss, shown compared with L. ailaonicum (Lai) and P. adspersus (Pad). The analyzed species were visualized with a custom script, alignment_plots.py (v1.0, https://github.com/ abmudd/Assembly). For each plot, the Hi-C inference-based centromeric regions are depicted with black stars, the X. tropicalis centromeric satellite repeat from tandem repeat analysis with a red star (on X. tropicalis chromosomes 7 and 1 (a, b), the stars overlap), the density of L1 repeats per chromosome with gold densities, and the runs of collinearity containing at least one kilobase of aligned sequence between the species with connecting black lines. kb kilobases, Mb megabases. Source data are provided as a Source Data le. (sub)metacentrics formed by centric fusion with other elements (Supplementary Table 8). We also observed end-to-end fusions78 of (sub)metacentric chromosomes, for example, the joining of D with K in E. pustulosus, and with element E in the common ancestor of pipids (Hymenochirus and Xenopus) (Figs. 1 and 3c). Since bicentric chromosomes are not stably propagated through mitosis, one of the two ancestral centromeres brought together by end-to-end fusion must be lost or inactivated, as shown in Fig. 3c for the ancient DE fusion in pipids. We note that the D centromere persists in both end-to-end fusions involving D, suggesting that centromeres derived from different ancestral elements may be differentially susceptible to silencing, although with only two examples this could have happened by chance. Using the pericentromeric and subtelomeric repeats landscape as a proxy, we found several examples of end-to-end chromosome fusions in which residual subtelomeric signals are preserved near the presumptive junctions (Fig. 3 and Supplementary Fig. 8). These include the end-to-end fusion of X. tropicalis-like chromosomes 9 and 10 (elements L and M) to produce the X. laevis chromosome 9_10 progenitor that is found in both the L and S subgenomes of this allotetraploid27. These X. laevis chromosomes display evidence of decaying subtelomeric signatures in the region surrounding the ancestral LM fusion (Fig. 1 and Supplementary Fig. 8a, b). Similarly, enrichment of subtelomerically-associated repeats is observed in H. boettgeri chromosome 8_10 (Supplementary Fig. 8ce) near the junction between the portions of the chromosome with M and J/K ancestry (the J/K fusion occurred near the base of pipids). In both cases, the centromere from element M (i.e., the centromere in X. tropicalis chromosome 9) is maintained after fusion. The inversion of the p-arm from chromosome 8S also has evidence of decaying sequence but the median is less than the median Jukes-Cantor (JC) distance at the chromosome 9_10 fusion, suggesting that the fusion preceded the inversion. Rate of karyotype change Nature Communications | (2024)15:579 The long-range and, in most cases, chromosome-scale collinearity (Supplementary Fig. 7 and Supplementary Table 9) among the frog species we examined, despite a combined branch length of 1.05 billion years (Supplementary Tables 10 and 11), parallels the conserved synteny observed in birds79 and reptiles80, but differs from the substantial chromosome variation found in mammals22,41. Maintenance of collinear blocks may reect an intrinsically slow rate of rearrangement in frogs, perhaps a consequence of large regions devoid of recombination, or selection favoring retention of specic gene order and chromosome structure related to chromosomal functions. We inferred 8 fusions, 2 ssions, one pairwise, and one four-way reciprocal fusion; counting the last as a composite of three pairwise rearrangements yields a total of 17 translocations (excluding smaller intra-chromosome rearrangements) corresponding to an average rate of one karyotype change every 62 million years (Fig. 1 and Table 1). This rate is similar to the rate of one chromosome number change every 70 to 90 million years as previously proposed for frogs and some mammals33,37 but still slower than karyotype change rates for most mammals81 and many reptiles82. Of course, our rate calculation is based on only seven species, and the rate may vary depending on the species analyzed. Some frog taxa, such as Eleutherodactylus spp. (2n = 1632) and Pristimantis spp51. (2n = 2238), have experienced higher rates of karyotype change. On the other hand, other lineages, such as those leading to Leptobrachium ailaonicum, L. leishanense14, and Rana temporaria83, have had no detectable inter-chromosome exchange over the past 205 million years (Fig. 1). Nonetheless, this analysis of chromosome variation across the frog lineage is consistent with an overall slow rate of karyotype evolution84. Considering rearrangement rate variation across taxa, we can ask whether any of the individual branches show an unusually high or low number of translocations relative to the overall pipanuran rate. The absolute karyotype stasis of L. ailaonicum over ~200 My is only 6 Article marginally slower than the pipanuran average (two-sided test, P = 0.04 under a simple Poisson model of 1 change every 62 My, before familywise correction for testing of multiple lineages). Conversely, the E. coqui lineage has experienced six translocations during a time interval in which only one rearrangement would be expected. This is a signicant enrichment relative to the Poisson model (P = 1 103) and is the only branch on which the constant rate hypothesis is rejected. Notably, Euleutherodactylus is the most karyotypically variable frog genus, suggesting possible ongoing karyotypic instability84,85. Regarding chromosome stability, our collection only includes one example in which a chromosome arm is disrupted by translocation; all other changes are either Robertsonian (involving breaks near a centromere) or end-to-end (near a telomere). This observation allows us to reject (P < 4 104) a simple random break model, under which we would expect ~12.3 chromosome arms to be broken across our phylogeny (Supplementary Note 4). This suggests that centromeric and telomeric regions are more prone to breakage, and/or breaks within chromosome arms are selected against. The latter model is consistent with a reduced probability of xation of reciprocal (partial-arm) translocations due to selection against reduced fertility in heterozygotes75, which can be overcome by genetic drift under some conditions76. Centromeres, satellites, and pericentromeric repeats The stasis of Xenopus chromosomes relative to other frogs (see above) allows us to examine the repetitive landscape of chromosomes that are not frequently rearranged by translocation and may be approaching a structural equilibrium. Vertebrate centromeres are typically characterized by tandem families of centromeric satellites (e.g., the alpha satellites of humans) that bind to the centromeric histone H3 protein, Cenp-a, a centromere-specic variant of histone H365,86. Cenp-a binding satellites have been described in X. laevis87, and here we nd distantly related X. tropicalis satellite sequences that also co-precipitate with Cenp-a. Thus, chromatin immunoprecipitation and sequencing (ChIP-seq) shows that Cenp-a binding coincides with the predictions of centromere positions derived from chromatin conformation analysis and repetitive content (Supplementary Figs. 5ac and 9ac and Supplementary Tables 12 and 13). Importantly, this concordance supports the prediction of centromere position for other species that we infer below. The Cenp-a-bound sequences are arrays of 205-bp monomers that share a mean sequence identity greater than 95% at the nucleotide level, with a specic segment of the repeating unit showing the greatest variability (Supplementary Fig. 9d, e). The X. tropicalis centromere sequence is different from centromeric-associated repeats found in X. laevis87,88, suggesting the sequences evolve rapidly after speciation but are maintained across chromosomes within the species. All pericentromeric regions of (sub)metacentric X. tropicalis chromosomes are enriched in retrotransposable repetitive elements (15 Mb regions shown in Fig. 2). In other vertebrate species and Drosophila, retrotransposable elements from the pericentromeric regions are involved in the recruitment of constitutive heterochromatin components89,90. Among the pericentromerically-enriched repeats we identied specic families belonging to LTR retrotransposons (Ty3), non-LTR retrotransposons (CR1, Penelope, and L1), and DNA transposable elements (PIF-Harbinger and piggyBac families) (Fig. 2 and Supplementary Fig. 5). CR1 (CR1-2_XT) is the most prevalent and among the youngest of all pericentromeric retrotransposons (mean JukesCantor (JC) distance to consensus of 0.05). In contrast, L1 and Penelope types have a mean JC greater than 0.4 (Supplementary Fig. 5). The age of the repeats, indirectly measured by the JC distance, suggests that pericentromeric retrotransposons have experienced different bursts of activity and tendency to insert near the centromere. Expression of active retrotransposons and random insertion can compromise chromosome stability, and because silencing of these is crucial, genomes develop mechanisms to rapidly silence them. Such Nature Communications | (2024)15:579 https://doi.org/10.1038/s41467-023-43012-9 insertions may be positively selected, and therefore amplied, to establish pericentromeric heterochromatin, but may be counterselected when they insert in gene-rich chromosome arms. Recombination and extended subtelomeres With chromosome sequences in hand, we studied the distribution of recombination along X. tropicalis chromosomes using a previously generated Nigerian-Ivory Coast F2 cross25 (Supplementary Note 5 and Supplementary Data 2). Half of the observed recombination is concentrated in only 160 Mb (11.0% of the genome) and 90% of the observed recombination occurs in 540 Mb (37.3%). In contrast, the extended central regions of each chromosome are cold, with recombination rates below 0.5 cM/Mb and that are often indistinguishable from zero in our data (Supplementary Fig. 10a, b and Supplementary Table 14). Strikingly, we nd that (sex-averaged) recombination is concentrated within just 30 Mb of the ends of each chromosome and occurs only rarely elsewhere (Supplementary Fig. 10a). The regions of the subtelomeres experiencing high recombination are nearly sixfold longer than in non-amphibian genomes91,92. The rates of recombination in Xenopus subtelomeres were not previously determined, since the repeat-rich subtelomeres were absent from earlier assemblies, and markers present in those regions showed insufcient linkage to be incorporated into linkage maps25. Elevated rates of recombination near telomeres and long central regions of low recombination have been observed in the macrochromosomes of diverse tetrapods, including birds92,93, snakes94, and mammals9597. This pattern appears to be independent of the involvement of the chromatin modier PRDM9 in dening recombination hotspots98 since dogs lack PRDM9 but show the same pattern, with elevated recombination in promoter regions and around CpG islands96. Conversely, snakes possess the prdm9 gene but also show hotspots of recombination concentrated in promoters and functional regions94. Since amphibians lack the prdm9 gene99, we further analyzed the genomic features that colocalized in subtelomeric regions prone to recombination. To assess sequence features associated with enriched recombination, we focused on the extended subtelomeres, dened as the terminal 30 Mb of all (sub)metacentric chromosomes and the terminal 30 Mb excluding the 15 Mb surrounding the pericentromeric regions of acrocentric chromosomes (3, 8, and 10) (Fig. 2). The median recombination rate in the extended subtelomeres (1.72 cM/Mb) is over tenfold higher than the median rate observed in the rest of the chromosome arms (0.14 cM/Mb) (two-sample KolmogorovSmirnov test, two-sided, Hochberg-corrected P = 5.2 10321) (Supplementary Fig. 10c and Supplementary Note 5). The recombination rate in the 5-Mb region surrounding the centromeric tandem repeats is even lower (0.01 cM/Mb). Since constitutive heterochromatin in pericentromeric regions is known to repress recombination, this observation is expected (reviewed in refs. 100,101). However, the centromeres of acrocentric chromosomes lie within 30 Mb of telomeres and preclude the presence of extended subtelomere-associated repeats (Fig. 2 and Supplementary Fig. 11). We examined the relationship between rates of recombination against repetitive elements and sequence motifs associated with recombination hotspots in other vertebrate species (Supplementary Fig. 12a and Supplementary Table 14). Similar to chicken and zebra nch, recombination is the highest in subtelomeres and positively correlates with GC content92,93,102, which is consistent with GC-biased gene conversion83,103,104 in recombinogenic regions (median GC = 42.5% in the 74 Mb in which half of the recombination occurs) vs. the nonrecombinogenic centers of chromosomes (median 38.8%). As in zebra nch (Supplementary Fig. 13), recombination in X. tropicalis is strongly correlated with satellite repeats (Pearsons correlation, r = 0.68, R2 = 0.457). The high density of satellite repeats (Supplementary Table 15) in highly recombinogenic subtelomeric regions suggests that 7 Article https://doi.org/10.1038/s41467-023-43012-9 unequal crossing over during meiotic recombination mediates tandem repeat expansions105,106. Notably, in the extended subtelomeric regions tandem repeats are enriched in specic tetrameric sequences (TGGG, AGGG, and ACAG) compared to non-tandem repeats (Supplementary Fig. 12b). In contrast, centromeric tandem repeats are completely devoid of these short sequences. Some of the tandem arrays enriched in the terminal 30 Mb of all chromosomes derive from portions of transposable elements, such as SINE/tRNA-V, LINE/CR1, DNA/Kolobok-2 (Supplementary Fig. 11 and Supplementary Table 16). For example, the minisatellite expansion that arose from the family of SINE/tRNA-V present in the pipid lineage107 amplied a 52-bp portion of the 3UTR-tail from the SINE/ tRNA-V element in Xenopus tropicalis and other frog species (Supplementary Table 17). Although intact SINE/tRNA-V elements are distributed throughout the genome, the minisatellite fragment is only expanded in subtelomeric SINE/tRNA-Vs, suggesting that recombination in subtelomeres has driven minisatellite expansion (Supplementary Figs. 11 and 14). Interestingly, although the satellite expansions are similar in X. laevis and X. tropicalis, they differ in other frogs, suggesting that different satellite expansions can occur repeatedly during the maintenance of the long subtelomeric regions (see below). We hypothesize that the high rate of recombination in the extended subtelomeres of frog chromosomes drives tandem repeat expansion through illegitimate homologous recombination and, in the process, increases GC content (Supplementary Fig. 14d, e). Unfortunately, it is difcult to resolve cause and effect with observational data, To further rene our understanding of chromosome structure in X. tropicalis, we studied chromatin conformation capture (Hi-C) data from nucleated blood cells. These experiments link short reads representing sequences in close three-dimensional proximity108. Figure 4 shows mapped Hi-C read pairs for chromosomes 1 and 2, with different minimum mapping quality thresholds above and below the diagonal (Supplementary Fig. 1e and Supplementary Note 5). We consistently observe a wing of intra-chromosome contacts transverse to the main diagonal, which (1) intersects the main diagonal near the cytogenetically dened Cenp-a-binding centromere, and (2) indicates contacts between p and q-arms (Supplementary Figs. 1e and 15). These observations imply that interphase chromosomes are folded at their centromeres, with contacts between distal arms. We also observe enriched inter-chromosome contacts among centromeres and among chromosome arms along a centromere-to-telomere axis, suggesting that chromosomes are organized in a polarized arrangement in the nucleus (Supplementary Figs. 9a and 15 and Supplementary Table 18). Notably, the correlation between centromere position and the observed intra-chromosome folding and inter-chromosome contacts at centromeres allows us to use Hi-C analysis and principal Fig. 4 | Organization of X. tropicalis chromosomes into Rabl-like conguration and distinct nuclear territories. a Hi-C contact matrices for chromosomes 1 and 2 (lower-left and upper-right gold boxes, respectively) showing features of the threedimensional chromatin architecture within X. tropicalis blood cell nuclei. Blue pixels represent chromatin contacts between XY pairs of 500 kb genomic loci, with intensity proportional to contact frequency. Hi-C read pairs are mapped stringently (MQ 30) above the diagonal and permissively (MQ 0) below the diagonal. The characteristic A/B-compartment (checkerboard) and Rabl-like (angel wing) interarm contact patterns within each chromosome are evident. Above the diagonal, an increased frequency of interchromosomal chromatin contacts is observed between pericentromeres (connected by dotted lines) and between chromosome arms (Supplementary Tables 18, 19, and 21), suggesting a centromere-clustered organization of chromosomes in a Rabl-like conguration. Below the diagonal, high-intensity pixels near the ends of chromosomes not present above the diagonal suggest a telomere-proximal spatial bias in the distributions of similar genomic repeats. See Supplementary Fig. 1e for a plot showing all chromosomes. b Chromosome territories within the nucleus. Yellow, white, and blue colors indicate the normalized relative enrichment, parity, and depletion of chromatin contacts between non-homologous chromosomes (Supplementary Tables 21 and 22). For example, chromosome 1 exhibits higher relative contact frequencies with all chromosomes except chromosomes 7, 9, and 10, which are generally depleted of contacts except among themselves (MQ 30; 2 (81, n = 24,987,749) = 3,049,787; Hochberg-corrected P < 4.46 10308; Relative range: 0.827741.16834). Note, due to the inbred nature of the Nigerian strain, contacts could not be partitioned by haplotype, and so the results reported here represent chromosomal averages. c Schematic representation of chromosome territories from (b). The size of each chromosome number is approximately proportional to the number of enriched interactions. Darker and lighter colors indicate chromosomes nearer and more distant to the reader, respectively. Mb megabases, MQ mapping quality. Source data are provided as a Source Data le. Nature Communications | (2024)15:579 and we cannot rule out the alternative hypothesis that meiotic recombination is promoted by preferential DNA breakage at short sequence motifs (Supplementary Fig. 12b), which is then repaired by homologous recombination. Chromatin conformation correlates with cytogenetic features 8 Article component analysis (PCA) of intra- and inter-chromosome contacts109 to infer the likely centromeric positions based purely on Hi-C data in frogs whose cytogenetics are less well-studied (see below). Taken together, these intra- and inter-chromosome contacts in Xenopus blood cells are consistent with a Rabl-like (Type-I110) chromosome conguration111, 112. Such associations among centromeres and among telomeres, rst observed in salamander embryos111, have been observed in other animals110,113117, fungi110,118,119, and plants109,110,120122. Outside of mammals, Rabl-like contacts have been observed in a wide diversity of taxa. Hoencamp et al.110. surveyed 24 plant and animal species using Hi-C and observed Rabl-like patterns in 14 (58.3%) of them. Out of seven vertebrates sampled, however, only Xenopus laevis broblasts showed a Rabl-like pattern. We note that Hi-C patterns can depend on cell type, cell cycle stage, and developmental time; and while Rabl-like Hi-C patterns are often absent from tissue samples used in mammalian genome sequencing projects, they have been observed in studies of mouse and human cell lines (Supplementary Note 5). In X. tropicalis, this conguration is understood to be a relict structure from the previous mitosis123,124 in which the chromosomes have become elongated and telomeres clustered on the inner nuclear periphery. Dernburg and colleagues125 reasoned that the Rabl conguration observed in Drosophila embryonic nuclei126,127 is a result of anaphase chromosome movement and, due to their rapidly dividing nature, such chromosomes are unable to relax into a diffused chromatin state. Consistent with this, we nd that Rabl-like chromosomal interarm contacts in early frog development (NF stages 823) appear more tightly constrained (mean SEM: sum of squared distances [SSD] 1.384 0.066, centromere-to-telomere-polar interarm contact enrichment [CTP] 2.492 0.179) in these rapidly dividing cells. Notably, more specialized (liver and brain) X. tropicalis adult tissues, except for blood cell nuclei (SSD 1.465, CTP 1.813), show less chromosomal interarm constraint (mean SEM: SSD 5.233 1.258, CTP 1.362 0.153) (Supplementary Fig. 16, Supplementary Table 19, and Supplementary Note 5). Although it is possible that some amount of Hi-C signal may be due to residual incompleteness in the assembly and concomitant mismapping of reads to repeat sequences, these observations are robust to quality ltering, even when using singlecopy sequences. Furthermore, such contacts are similarly weak in sperm cells16 (SSD 6.285, CTP 1.056), a control that argues strongly against sequence mismapping artifacts (Supplementary Note 5). As noted above, the presence and strength of Rabl-like congurations vary depending on the tissue, cell type, and developmental time. Such variability highlights the need to sample a broader diversity of tissues and time points to characterize completely the Rabl-like chromosome structures in X. tropicalis. Chromatin compartments Chromatin contacts in human108,128,129, mouse129, chicken130 and other phylogenetically diverse species131133 often show a characteristic checkerboard pattern that is superimposed on the predominant neardiagonal signal. This pattern implies an alternating A/B-compartment structure with enriched intra-compartment contacts within chromosomes (Fig. 5a), which has been linked with G-banding in humans134. X. tropicalis also exhibits an A/B-compartment pattern, which emerges as alternating gene-rich (A) and gene-poor (B) regions (median 19.99 genes/Mb and 9.99 genes/Mb, respectively) (Fig. 5b). Despite their twofold difference in gene content, A and B-compartment lengths are comparable, with approximately exponential distributions (Supplementary Fig. 17). The arithmetic mean sizes are A = 1.32 Mb, B = 1.48 Mb; the corresponding geometric means (i.e., the exponential of the arithmetic mean of logarithms of lengths) are somewhat shorter (A = 0.807 Mb, B = 0.946 Mb). A/B compartments are also differentiated by repetitive content129, with A-compartment domains showing slight enrichment (1.211.44-fold) in DNA transposons of the DNA/Kolobok-T2, DNA/hAT-Charlie, and Mariner-Tc1 families. Nature Communications | (2024)15:579 https://doi.org/10.1038/s41467-023-43012-9 B-compartment domains had signicantly higher enrichment for DNA transposons (DNA/hAT-Ac, Mar-Tigger) and retrotransposons (Ty3/ metaviridae and CR1), among other repeats (1.122.11-fold) (Fig. 5c, Supplementary Table 20). The association between repeats overrepresented in A and B compartments is also captured in one of the principal components obtained from the repeat densities of all chromosomes (Supplementary Note 5); we detect a modest negative correlation (Pearsons r = 0.44) between A/B compartments and the third principal component obtained from the repeat density matrix (Supplementary Fig. 5b). The association between chromatin condensation and repeat type could be due to a preference for certain transposable elements to insert in specic chromatin contexts, or chromatin condensation to be controlled, in part, by transposable element content, or a combination of these factors. However, we were unable to nd any correlation of A/B compartments with the G-banding of condensed chromosomes in X. tropicalis135,136. Higher-order chromatin interactions Chromatin conformation contacts also provide clues to the organization of chromosomes within the nucleus. We observe non-random (2 (81, n = 24,987,749) = 3,049,787; Hochberg-corrected P < 4.46 10308) associations between chromosomes in blood cell nuclei (Fig. 4b and Supplementary Tables 21 and 22): (a) chromosome 1 is enriched for contacts with chromosomes 28 (mean 1.05 enrichment), and depleted of contacts with 9 and 10 (mean 0.89); (b) among themselves, chromosomes 28 show differential contact enrichment or depletion; and (c) chromosomes 9 and 10 are enriched (1.17) for contacts with one another, but are depleted of contacts with all other chromosomes. These observations suggest the presence of distinct chromosome territories111,137139, where chromosomes 28 are localized more proximal toand arrayed aroundchromosome 1, with chromosomes 9 and 10 relatively sequestered from chromosome 1 (Fig. 4c). The contact enrichment between chromosomes 9 and 10 is particularly notable because these short chromosomes (91.2 and 52.4 Mb, respectively) have become fused in the X. laevis lineage140, which might have been enabled by their persistent nuclear proximity141143. Between chromosomes, p-p and q-q arm interactions exhibit a small but signicant enrichment (1.059 enrichment; 2 (1, n = 24,786,496) = 17,037; Hochberg-corrected P < 4.46 10308) over p-q arm contacts. This is a general feature of (sub)metacentric chromosomes observed in other frog genomes (Supplementary Table 21), except E. coqui (0.928 enrichment; 2 (1, n = 6,850,547) = 3,914; Hochberg-corrected P < 4.46 10308), the chromosomes of which appear predominantly acrocentric or telocentric. Finally, the p-arms of chromosomes 3, 4, 8, and 9 are enriched for contacts with both p and q-arms of chromosome 10, with the acrocentric chromosomes 3 and 8 showing the strongest relative enrichment and a slight preference between p-arms. The q-arms of chromosomes 3 and 8, however, exhibit a slight enrichment for contacts with the larger (sub)metacentric chromosomes 1, 2, 4, and 5. Taken together, these observations suggest possible colocalization of the p and q-arms of chromosomes 3 and 8 in X. tropicalis blood cell nuclei. Future impacts Anuran amphibians play a central role in biology, not simply as a globally distributed animal group, but also as key subjects for research in areas that range from ecology and evolution to cell and developmental biology. The genomic resources generated here will thus provide important tools for further studies. Given the crucial role of X. tropicalis for genomic analysis of development and regeneration144,145, the improvements to our understanding of its genome reported here will provide a more nely-grained view of biomedically important genetic and epigenetic mechanisms. This new genome is also important from the standpoint of evolutionary genomics, as comparisons between the genomes of X. tropicalis and X. laevis shed light on the 9 Article c 210 Compartment Genes / Mb 200 190 180 170 160 100 25 A 120 d 110 B 1 2 3 4 5 6 7 8 9 10 100 90 70 60 400 200 0.10 0.05 0.00 0.05 0.10 DNA/hAT-Ac DNA DNA/TcMAr-Tigger LTR/Ty3-Metaviridae LINE1/CR1 Ty3-Metaviridae DNA_transposon hAT DIRS 21 10 0 210 200 190 180 170 160 150 140 130 120 110 100 80 90 70 60 50 40 30 20 0 10 0.15 e Eigenvector (HiC) 0.15 1 Eigenvector (PC3: Repeat density) 210 200 190 180 170 160 150 140 130 120 110 80 90 100 70 60 50 40 30 20 0 10 10 Transposable_Element 20 LTR_Retrotransposon 30 Mariner/Tc1 DNA/Kolobok-T2 40 DNA/TcMar-Tc1 0 50 0 Repeat class 600 Repeats / Mb Position (Mb) 0 130 80 Eigenvector 50 50 140 b A B 75 0 150 Chromosome 100 DNA/hAT-Charlie a https://doi.org/10.1038/s41467-023-43012-9 0 Position (Mb) 20 40 60 80 100 120 140 160 180 200 Position (Mb) Fig. 5 | A/B-compartment structure and gene/repeat densities. a Correlation matrix of intra-chromosomal Hi-C contact densities between all pairs of nonoverlapping 250 kb loci on chromosome 1. Yellow and blue pixels indicate correlation and anti-correlation, respectively, and reveal which genomic loci occupy the same or different chromatin compartment. Black pixels indicate weak/no correlation. b The rst principal component (PC) vector revealing the compartment structure along chromosome 1, obtained by singular value decomposition of the correlation matrix in panel a. Yellow (positive) and blue (negative) loadings indicate regions of chromosome 1 partitioned into A and B compartments, respectively. c Gene density (genes per megabase) distributions in A (yellow) vs. B (blue) compartments genome-wide and per chromosome. Sample sizes and signicance statistics provided in Supplementary Table 20. d Repeat classes signicantly enriched by density (repeats per megabase) in A (yellow) vs. B (blue) compartments. Sample sizes and signicance statistics provided in Supplementary Table 20. Each boxplot summarizes the combined (A + B) density distribution (Y-axis) per class (X axis); lower and upper bounds of each box (black) delimit the rst and third quartiles, respectively, and whiskers extend to 1.5 times the interquartile range, while the median per class is represented as a lled white circle. e The PC3 loadings (purple line) from the repeat density matrix inversely correlate with alternating A/B-compartment loadings (green) for chromosome 1. See Supplementary Fig. 5b for all chromosomes. Purple rectangles plotted on the X axis denote subtelomeric regions, the red rectangle spans the pericentromere, and the black point marks the median centromere-associated tandem repeat position. Mb megabases. Source data are provided as a Source Data le. consequences of genome duplication145. The new genome described here for H. boettgeri, another pipid frog, is also signicant in this regard, as it enables an interesting comparison of Xenopus genomes to that of a closely related outgroup. Moreover, the genomes of E. coqui and E. pustulosus provide a foundation for future studies of the evolution of ontogenies and their underlying developmental mechanisms, as E. coqui is a direct-developing frog with no tadpole stage16 and E. pustulosus, a foam-nesting frog, is a model for studying mating calls and female mate choice18. In addition to their interesting life histories, both frogs display distinct patterns of gastrulation146,147. Finally, recent work has demonstrated the efcacy of genetic or genomic analysis for understanding the impact of chytrid fungus on various amphibian species148. A deeper and broader understanding of amphibian genomes will be useful in the context of the global decline of amphibian populations149,150. Note added in proof: The recent nding of tetraploid dwarf clawed frogs from the Congo suggests that the diploid Hymenochirus we studied may distinct from H. boettgeri151. Xenopus tropicalis genomic DNA extraction and sequencing Methods This study complies with the ethical standards set forth by the Institutional Animal Care and Use Committee (IACUC) protocols at the University of California Berkeley, Yale University, University of Cincinnati, and the University of the Pacic. The IACUC and associated facilities are subject to review and oversight by NIHs Ofce of Lab Animal Welfare. Nature Communications | (2024)15:579 High molecular weight DNA was extracted from the blood of an F17 Xenopus tropicalis Nigerian strain female25. Paired-end (PE) Illumina whole-genome shotgun (WGS) libraries were constructed by the QB3 Functional Genomics Laboratory (FGL) using a KAPA HyperPrep Kit and sequenced on an Illumina HiSeq 2500 as 2 250 bp reads by the Vincent J. Coates Genomics Sequencing Lab (VCGSL) at the University of California, Berkeley (UCB). Single-Molecule Real-Time (SMRT) continuous long-read (CLR) sequencing was performed at the HudsonAlpha Institute for Biotechnology (HAIB) on Pacic Biosciences (PacBio) RSII machines with P6-C4 chemistry (Supplementary Data 1). Chromium Genome linked-read (10x Genomics) sequencing was carried out by HAIB on an Illumina HiSeq X Ten. Hi-C libraries were constructed by Dovetail Genomics LLC. See Supplementary Note 1 for more detailed extraction and sequencing methods. Xenopus tropicalis genome assembly and annotation Chromium linked-read (10x Genomics) data were assembled with Supernova152 (v1.1.5). This assembly was used to seed the assembly of PacBio CLR data using DBG2OLC153 (commit 1f7e752). An independent PacBio-only assembly was constructed with Canu154 (v1.6-132-gf9284f8). These two assemblies were combined, or metassembled, using MUMmer155 (v3.23) and quickmerge156 (commit e4ea490) (Supplementary Fig. 1a). Residual haplotypic redundancy was identied and removed (Supplementary Fig. 1b). The non-redundant metassembly 10 Article was scaffolded with Sanger paired-ends and BAC-ends45 using SSPACE157 (v3.0) and Hi-C using 3D-DNA117,158,159 (commit 2796c3b), then manually curated in Juicebox160,161 (v1.9.0). The assembly was polished with Arrow162 (smrtlink v6.0.0.47841), Pilon163 (v1.23), and then FreeBayes164 (v1.1.0-54-g49413aa) with ILEC (map4cns commit dd89f52, https:// bitbucket.org/rokhsar-lab/map4cns). The genome was annotated with the DOE-Joint Genome Institute (JGI) Integrated Gene Call (IGC) pipeline165 (v5.0) using transcript assemblies (TAs) generated with Trinity166,167 (v2.5.1) from multiple developmental stages and tissues (Supplementary Data 1). RepeatModeler168 (v1.0.11) was run on all frog species. The frog and ancestral repeat libraries from RepBase169 (v23.12) were combined with the repeat consensuses identied by RepeatModeler. The merged repeat library was used to annotate repeats of all frogs with RepeatMasker170 (v4.0.7). See Supplementary Note 2 for more detailed assembly and annotation methods. Hymenochirus boettgeri metaphase chromosome spread H. boettgeri were obtained from Albany Aquarium (Albany, CA). Stage 26 tadpoles (n = 10) were incubated at room temperature in 0.01% colchicine and 1 MMR for 46 h. After removing the yolky ventral portion of the tadpoles, the remaining dorsal portions were pooled together in deionized water and allowed to stand for 20 min. The dorsal portions were transferred to 0.2 mL of 60% acetic acid in deionized water and allowed to stand for 5 min. The tissue was then pipetted onto a positively charged microscope slide, and excess acetic acid was blotted away. To atten the tissue and promote chromosome spreading, the slide was covered with a coverslip, and a lead brick was placed on top of it for 5 min. The slide and coverslip were then placed on dry ice for 5 min. The coverslip was removed from the frozen slide, and the slide was stained with 0.1 mg/mL Hoechst Stain solution for 5 min. A fresh coverslip was then mounted on the slide using VectaShield, and the edges were sealed with nail polish. Chromosomes in metaphase spreads (Supplementary Fig. 3a) were imaged on an Olympus BX51 Fluorescence Microscope run with Metamorph (v7.0) software using a 60 oil objective. Chromosome number was counted in 75 separate metaphase spreads. Genome and transcriptome sequencing of ve pipanurans Illumina PE 10x Genomics Chromium linked-read whole-genome libraries for E. pustulosus (from liver), E. coqui (from blood), and H. boettgeri (from liver) were sequenced on an HiSeq X at HAIB. PacBio SMRT Sequel I CLR data were generated at UC Davis DNA Technologies and Expression Analysis Core for each of E. pustulosus and H. boettgeri from liver samples. In addition, two Illumina TruSeq PE libraries (from kidney) and two Nextera mate-pair libraries (from liver) for E. coqui were prepared. Hi-C libraries were prepared for H. boettgeri, E. pustulosus, and E. coqui using the DovetailTM Hi-C Kit for Illumina (Beta v0.3 Short manual) following the Animal Tissue Samples protocol, then sequenced on a HiSeq 4000 at the VCGSL or a NextSeq at Dovetail Genomics. Illumina TruSeq Stranded mRNA Library Prep Kit (cat# RS-122-2101 and RS-122-2102) libraries were prepared from E. pustulosus stages 45 and 56 whole tadpoles (gut excluded) and various adult tissues dissected from frogs maintained at the University of the Pacic. Brain (n = 3), dorsal skin (n = 2), eggs (n = 2), eye (n = 2), heart (n = 2), intestine (n = 2), larynx (n = 3), liver (n = 2), lung (n = 2), and ventral skin (n = 2) samples were washed twice with PBS, homogenized in TRIzol Reagent, and centrifuged, followed by ash freezing of the supernatant. RNA was isolated following the TRIzol Reagent User Guide (Pub. No. MAN0001271 Rev. A.0) protocol. In addition, H. boettgeri eggs were homogenized in TRIzol Reagent and processed according to the manufacturers instructions. RNA was then isolated using the QIAGEN RNeasy Mini Kit (cat# 74104). An Illumina mRNA library was prepared using the Takara PrepX RNA-Seq for Illumina Library Kit (cat# 640097) by the QB3 FGL at UCB. All libraries were sequenced at the VCGSL on an Nature Communications | (2024)15:579 https://doi.org/10.1038/s41467-023-43012-9 HiSeq 4000 as 2 151 bp reads. See Supplementary Note 3 for additional details about DNA/RNA extractions and library preparations, and Supplementary Data 1 for a complete list of DNA/RNA sequencing data generated for E. coqui, E. pustulosus, and H. boettgeri. Assembly and annotation of ve pipanuran genomes E. pustulosus and H. boettgeri contigs were assembled with Supernova152 (v2.0.1). E. coqui contigs were assembled with Meraculous171,172 (v2.2.4) and residual haplotypic redundancy was removed using a custom script (align_pipeline.sh v1.0, https://github. com/abmudd/Assembly) before scaffolding with SSPACE157 (v3.0). E. pustulosus and H. boettgeri contigs were ordered and oriented using MUMmer155 (v3.23) alignments to PBEC-polished (map4cns commit dd89f52, https://bitbucket.org/rokhsar-lab/map4cns) DBG2OLC153 (commit 1f7e752) hybrid contigs (Supplementary Note 3). All three assemblies were scaffolded further with linked reads and Scaff10X (v2.1, https://sourceforge.net/projects/phusion2/les/scaff10x). E. pustulosus and H. boettgeri chromosome-scale scaffolds were constructed with Dovetail Genomics Hi-C via the HiRise scaffolder173, followed by manual curation in Juicebox158,160,161 v1.9.0. Due to the fragmented nature of the E. coqui assembly, initial chromosome-scale scaffolds were rst constructed by synteny with E. pustulosus, then rened in Juicebox158,160,161 v1.9.0. Gaps in the E. pustulosus and H. boettgeri assemblies bridged by PacBio reads were resized using custom scripts (pbGapLen v0.0.2, https://bitbucket.org/rokhsar-lab/ xentr10/src/master/assembly) and lled with PBJelly174 (PBSuite v15.8.24). These two assemblies were polished with FreeBayes (v1.1.054-g49413aa) and ILEC (map4cns commit dd89f52, https://bitbucket. org/rokhsar-lab/map4cns). A nal round of gap-lling was then performed on the three assemblies using Platanus175 (v1.2.1). Previously published L. ailaonicum30 (GCA_018994145.1) and P. adspersus28 (GCA_004786255.1) assemblies were manually corrected in Juicebox158,160,161 (v1.11.08) using their respective Hi-C and Chicago data (Supplementary Data 1). Gaps in the corrected P. adspersus scaffolds were resized with PacBio reads (as described above) and lled using Platanus175 (v1.2.1) with published Illumina TruSeq PE data obtained from NCBI (PRJNA439445). As described elsewhere176, all assemblies were screened for contaminants before scaffolding, and only nal scaffolds and contigs longer than 1 kb were retained for downstream analyses. More details on assembly procedures can be found in (Supplementary Note 3). Genomic repeats in all ve species were annotated with RepeatMasker168,170 (v4.0.7 and v4.0.9) using the repeat library generated above. Protein-coding genes were annotated for E. coqui, E. pustulosus, H. boettgeri, and P. adspersus using the DOE-JGI IGC165 (v5.0) pipeline with homology and transcript evidence. For each respective species, newly generated RNA-seq data were combined with public H. boettgeri27 (BioProject PRJNA306175) and P. adspersus28 (BioProject PRJNA439445) data and E. coqui data (stages 7, 10, and 13 hindlimb [Harvard University]; stage 910 tail n skin [French National Center for Scientic Research]). TAs used as input to IGC were assembled with Trinity166,167 (v2.5.1) and ltered using the heuristics described in Supplementary Note 3. Synteny and ancestral chromosome inference One-to-one gene ortholog set between frog proteomes was obtained from the output from OrthoVenn264 (https://orthovenn2. bioinfotoolkits.net) using an E value of 1 105 and an ination value of 1.5 (Supplementary Note 4). The assemblies of all frog species and axolotl were pairwise aligned against the X. tropicalis genome using Cactus177 (commit e4d0859) (Supplementary Note 4). Pairwise collinear runs were merged into multiple sequence alignments with ROAST/MULTIZ178 (v012109) in order of phylogenetic topology from TimeTree179 (http://www.timetree.org), then sorted with LAST180 (v979) (Supplementary Note 4). 11 Article Phylogeny and estimation of sequence divergence Fourfold degenerate bases of one-to-one orthologs were obtained and reformatted from the MAFFT (v7.427) alignment as described in ref. 176 (Supplementary Note 4). The maximum-likelihood phylogeny was obtained with RAxML181 (v8.2.11) using the GTR+Gamma model of substitution with outgroup Ambystoma mexicanum. Divergence times were calculated with MEGA7182 (v7.0.26) with the GTR+Gamma model of substitution using Reltime method183. Chromosome evolution A custom script176 (cactus_lter.py v1.0, https://github.com/abmudd/ Assembly) was used to extract pairwise alignments from the ROASTmerged MAF le and convert alignments into runs of collinearity. The runs of collinearity were visualized with Circos184 (v0.69-6) (Supplementary Note 4) and JCVI185 (jcvi.graphics.karyotype v0.8.12, https:// github.com/tanghaibao/jcvi). Centromeres, satellites, and pericentromeric repeats Tandem repeats were called using Tandem Repeats Finder69 (v4.09; params: 2 5 7 80 10 50 2000 -l 6 -d -h -ngs). To identify tandem repeats enriched in pericentromeric and subtelomeric regions, we extracted the monomer sequences of all tandem repeats overlapping the region of interest. A database of non-redundant monomers was created by making a dimer database. Dimers were clustered with BlastClust186 v2.2.26 (-S 75 -p F -L 0.45 -b F -W 10). A non-redundant monomer database was created using the most common monomer size from each cluster. The non-redundant sequences were mapped to the genome with BLASTN187 (BLAST+ v2.9.0; -outfmt 6 -evalue 1e3). The enriched monomeric sequences in centromeres and subtelomeres were identied by selecting the highest normalized rations of tandem sequence footprints in the region of interest over the remaining portions of the genome. For more detail, see Supplementary Note 5. Genetic variation Reads were aligned with BWA-MEM188 (v0.7.17-r1188) and alignments were processed using SAMtools189 (v1.9-93-g0ca96a4), keeping only properly paired reads (samtools view -f3 -F3852) for variant calling. Variants were called with FreeBayes164 (v1.1.0-54-g49413aa; --standardlters --genotype-qualities --strict-vcf --report-monomorphic). Only biallelic SNPs with depth within mode 1.78SDs were retained. An allelebalance lter [0.30.7] for heterozygous genotypes was also applied. Segmental heterozygosity/homozygosity was estimated using windows of 500 kb with 50-kb step using BEDtools190 (v2.28.0) for pooled samples or snvrate191 (v2.0, https://bitbucket.org/rokhsar-lab/wgsanalysis). For more detail, see Supplementary Note 2. GC content, gene, and repeat landscape GC-content percentages were calculated in 1-Mb bins sliding every 50 kb. Gene densities were obtained using a window size of 250 kb sliding every 12.5 kb. The repeat density matrix for X. tropicalis was obtained by counting base pairs per 1 Mb (sliding every 200 kb) covered by repeat families and classes of repeats. The principal component analysis (PCA) was performed on the density matrix composed of 7253 overlapping 1-Mb bins and 3070 repeats (Supplementary Note 5). The rst (PC1) and second (PC2) components were smoothed using a cubic spline method. Chromatin immunoprecipitation Xenopus tropicalis XTN-6 cells192 were grown in 70% calcium-free L-15 (US Biologicals cat# L2101-02-50L), pH 7.2/10% Fetal Bovine Serum/ Penicillin-Streptomycin (Invitrogen cat# 15140-163) at RT. Native MNase ChIP-seq protocol was performed as described previously in Smith et al.88. Approximately 40 million cells were trypsinized and collected; nuclei were isolated by dounce extraction and collected with a sucrose cushion. Chromatin was digested to mononucleosomes by Nature Communications | (2024)15:579 https://doi.org/10.1038/s41467-023-43012-9 MNase. Nuclei were lysed and soluble nucleosomes were extracted overnight at 4 C. Extracted mononucleosomes were precleared with Protein A dynabeads (Invitrogen cat# 100-02D) for at least 4 h at 4 C. A sample was taken for input after pre-clearing. Protein A dynabeads were bound to 10-g antibody (50 g/L nal concentration of either Rb-anti-Xl Cenp-a [cross-reactive with X. tropicalis], Rb-anti-H4 Abcam cat# 7311, or Rb-anti-H3 Abcam cat# 1791) and incubated overnight with precleared soluble mononucleosomes at 4 C. Dynabeads bound to 50 g/L nal concentration of Rabbit IgG antibody (Jackson ImmunoResearch cat# 011-000-003) were collected with a magnet and washed three times with TBST (0.1% Triton X-100) before elution with 0.1% SDS in TE and proteinase K incubation at 65 C with shaking for at least 4 h. Isolated and input mononucleosomes were size-selected using Ampure beads (Beckman cat# A63880) and prepared for sequencing using the NEBNext Ultra II DNA Library Prep Kit for Illumina (NEB cat# E7654). Three replicates were sequenced on an Illumina HiSeq 4000 lane 2 150 bp by the Stanford Functional Genomics Facility. PE reads were trimmed with Trimmomatic193 (v0.39), removing universal Illumina primers and Nextera-PE indices. Processed PE reads were mapped with Minimap2194 (v2.17-r941) against the unmasked genome reference. SAMtools189 (v1.9-93-g0ca96a4) was used for sorting and indexing the alignments. Read counts (mapping quality [MQ] 0) per 10-kb bin (nonoverlapping) for all samples were calculated with multiBamSummary from deepTools195 (v3.3.0). Read counts were normalized by the total number of counts in the chromosomes per sample (Supplementary Note 5). Peaks were called with MACS2196 (v2.2.7.1) and custom scripts (https://bitbucket.org/rokhsarlab/xentr10/src/master/chipseq). Recombination and extended subtelomeres The reads from the F2 mapping population25 were aligned to the v10 genome sequence using BWA-MEM188 (v0.7.17-r1188). Variants were called using FreeBayes164 (v1.1.0-54-g49413aa; --standard-lters --genotype-qualities --strict-vcf ). SNPs were ltered, and valid F2 mapping sites were selected when the genotypes of the Nigerian F0 and the ICB F0 were xed and different and there was a depth of at least 10 for each F0 SNP. Maps were calculated using JoinMap197 v4.1 (Supplementary Note 5, Supplementary Data 2). The variation on the linkage map was smoothed using the not-a-knot cubic spline function calculated every 500 kb. The Pearson correlation coefcient, r, was calculated between recombination rates and genomic features that include GC content, repeat densities, and densities of reported CTCF and recombination hotspots198,199. Chromatin conformations and higher-order interactions Hi-C read pairs were mapped with Juicer158,159 (commit d3ee11b) and observed counts were extracted at 1 Mb resolution with Juicer Tools (commit d3ee11b). Centromeres were estimated manually in Juicebox160 and rened with Centurion200 v0.1.0-3-g985439c using ICE-balanced MQ 0 matrices (https://bitbucket.org/rokhsar-lab/xentr10/src/master/ hic). Rabl-like chromatin structure was visualized with PCA from KnightRuiz201-balanced MQ 30 matrices and signicance was estimated by permutation testing (10,000 iterations, one-sided = 0.01) using custom R202 scripts. Rabl-like constraint between p- and q-arms was measured as the sum of square distances (SSD) in PC1-PC2 dimensions, calculated between nonoverlapping bins traveling sequentially away from the centromere. Inter-/intra-chromosomal contact enrichment analyses were quantied from MQ 30 matrices using 2 tests in R v3.5.0 (hic-analysis.R v1.0, https://bitbucket.org/rokhsar-lab/xentr10/ src/master/hic). See Supplementary Note 5 for more details. A/B compartments A/B compartments were called with custom R202 scripts (call-compartments.R v0.1.0, https://bitbucket.org/bredeson/artisanal) from KnightRuiz-balanced (observed/expected normalized) MQ 30 Hi-C 12 Article contact correlation matrices generated with Juicer158,159 (Supplementary Note 5). Pearsons correlation between PC1 from the Hi-C correlation matrix and gene density was used to designate A and B compartments per chromosome. https://doi.org/10.1038/s41467-023-43012-9 8. 9. Reporting summary Further information on research design is available in the Nature Portfolio Reporting Summary linked to this article. 10. Data availability Data supporting the ndings of this work are available throughout the main text, Methods, Supplementary Information, Supplementary Data, or archived in Zenodo (https://doi.org/10.5281/zenodo. 8393403). All newly generated assemblies, annotations, and raw data are deposited in the NCBI GenBank and SRA databases: X. tropicalis under BioProject accession codes PRJNA577946 and PRJNA526297, E. coqui under BioProject accession code PRJNA578591, E. pustulosus under BioProject accession code PRJNA578590, and H. boettgeri under BioProject accession code PRJNA578589. L. ailaonicum and P. adspersus re-assemblies were deposited at NCBI GenBank under accession DAJOPU000000000 and DYDO00000000, respectively; the versions described in this manuscript are DAJOPU010000000 [https://www.ncbi.nlm.nih.gov/nuccore/ DAJOPU000000000.1] and DYDO01000000 [https://www.ncbi. nlm.nih.gov/nuccore/DYDO00000000.1]. Raw X. tropicalis ChIP-seq data are available at the NCBI SRA under BioProject accession code PRJNA726269 and the processed data via the NCBI GEO database under series accession GSE199671. The E. coqui tail n RNA-seq data generated in this study have been deposited in the NCBI SRA database under accession code PRJNA1022815. The E. coqui hindlimb developmental series RNA-seq data are available under restricted access as the project is not yet published, access can be obtained by contacting Mara Laslo at ml125@wellesley.edu. Source data are provided with this paper. 11. 12. 13. 14. 15. 16. 17. 18. 19. Code availability All custom scripts used in this work are archived203 in Zenodo at https:// doi.org/10.5281/zenodo.8393403 and can be found via the project repository at https://bitbucket.org/rokhsar-lab/xentr10 (tag v1.0) or via the individual repositories linked therein: https://github.com/abmudd/ Assembly, https://bitbucket.org/bredeson/artisanal, https://bitbucket. org/rokhsar-lab/map4cns, https://bitbucket.org/rokhsar-lab/wgsanalysis, https://bitbucket.org/rokhsar-lab/gbs-analysis, and https:// gitlab.com/Bredeson/wombat. 20. 21. 22. 23. References 1. 2. 3. 4. 5. 6. 7. 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Bredeson, J. V. et al. Conserved chromatin and repetitive patterns reveal slow genome evolution in frogs. https://doi.org/10.5281/ zenodo.8393403 (2023). Acknowledgements We thank Karen Lundy and the Functional Genomics Laboratory at the University of California Berkeley for running quality control on extracted DNA and RNA and for preparing Illumina short-insert libraries; Oanh Nguyen and the DNA Technologies and Expression Analysis Cores at the University of California Davis Genome Center for preparing and sequencing PacBio libraries; Dovetail Genomics for providing the Hi-C library preparation kit, running quality control on Hi-C libraries, and preparing and sequencing Hi-C libraries; Shana McDevitt and the Vincent J. Coates Genomics Sequencing Laboratory at the University of California Berkeley for sequencing Hi-C and Illumina short-insert libraries; Shengqiang Shu for advice on the use of the IGC annotation pipeline. We thank Rick Elinson for providing E. coqui frogs and tissues. We thank Gary Gorbsky from the Oklahoma Medical Research Foundation and Marko Horb and the National Xenopus Resource at the MBL for providing the XTN-6 cell lines. We also thank Chunhui Hou and colleagues for permission to access their Hi-C data before publication. This study was supported by NIH grants R01HD080708 to D.S.R.; R01GM086321, R01HD065705 to D.S.R. and R.M.H.; R35GM127069 to R.M.H.; R35 GM118183 to R.H. A.B.M. was supported by NIH grants T32GM007127 and T32HG000047 and a David L. Boren Fellowship. D.S.R. is grateful for support from the Marthella Foskett Brown Chair in Biological Sciences; R.M.H., the C.H. Li 17 Article Distinguished Chair in Molecular and Cell Biology; and R.H., the Flora Lamson Hewlett chair in biochemistry. A.F.S. and O.K.S. were supported by R01GM074728, O.K.S. by NIH T32 GM113854-02 and NSF GRFP; M.K.K. and M.Lane by R01HD102186; J.H. by NSF grants DEB-1701591 and DBI1702263; M.Laslo, a Graduate Women in Science Fellowship; T.K. by the Basic Science Research Program, National Research Foundation of Korea (NRF), Ministry of Education (2018R1A6A1A03025810), Future-leading Project Research Fund (1.200094.01) of UNIST and the Institute for Basic Science (IBS-R022-D1); J.B.W. and H.S.P. by R01GM104853, R01HD085901; M.J.R. by NSF IOS-0910112; Smithsonian Tropical Research Institute; Clark Hubbs Regents Professorship; L.M.S. by the Centre National de la Recherche Scientique (PEPS ExoMod Triton) m National dHistoire Naturelle (Action Transversale du and the Museu Museum Cycles biologiques: Evolution et adaptation) and a Scientic council post-doctoral position to G.K. This work used the Vincent J. Coates Genomics Sequencing Laboratory at the University of California Berkeley, supported by NIH grant S10OD018174, and the DNA Technologies and Expression Analysis Cores at the University of California Davis Genome Center, supported by NIH grant S10OD010786. This research used the National Energy Research Scientic Computing Center, a Department of Energy Ofce of Science User Facility supported by contract number DE-AC02-05CH11231. L.M.S. acknowledges the Ecole Normale Superieure de PARIS genomic platform for RNA sequencing m and the PCIA high-performance computing platform at Museu National dHistoire Naturelle. https://doi.org/10.1038/s41467-023-43012-9 sequenced 10x Genomics, PacBio, and Illumina mate-pair libraries. D.H. prepared Hi-C libraries. R.D.D. and J.H.M. provided early access to the Pad assembly. N.B. (Eco) provided bioinformatic support. L.M.S. led the Eco efforts. R.M.H. and D.S.R. led the project. Competing interests D.S.R. is a member of the Scientic Advisory Board of, and a minor shareholder in, Dovetail Genomics LLC, which provides as a service the high-throughput chromatin conformation capture (Hi-C) technology used in this study. M.K.K. is President and co-founder of Victory Genomics, Inc. The remaining authors declare no competing interests. Additional information Supplementary information The online version contains supplementary material available at https://doi.org/10.1038/s41467-023-43012-9. Correspondence and requests for materials should be addressed to Daniel S. Rokhsar. Peer review information Nature Communications thanks Mark Blaxter and Amy Sater for their contribution to the peer review of this work. A peer review le is available. Reprints and permissions information is available at http://www.nature.com/reprints Author contributions J.V.B., A.B.M., S.M.R., T.M., R.M.H. and D.S.R. wrote the manuscript with feedback from M.Laslo, H.P.S., J.H., J.B.L., J.B.W., M.J.R., O.K.S., D.R.B., M.G.P., J.H., N.B., T.K., L.M.S., R.H., J.S., M.K.K., A.F.S. and D.H. Genomes were assembled by J.V.B., S.S.B. (Xtr); A.B.M., and K.C.B. (other frogs). S.M.R., A.B.M. and G.K. assembled transcripts and annotated genomes. S.M.R. and J.V.B. assessed gene completeness; S.M.R. analyzed repeat and recombination landscapes. S.M.R. and J.P. identied centromeric repeats. O.K.S., G.A.F. and A.F.S. conducted ChIP-seq experiments, and S.M.R. performed analysis. J.V.B. analyzed Hi-C features. T.M. constructed the linkage map. T.M. and J.V.B. analyzed heterozygosity. A.B.M. performed genome-wide comparisons. K.E.M. and R.H. examined Hbo metaphase spreads. M.K.K. and M.Lane inbred Xtr frogs. R.M.H. (Xtr); M.G.P. (Epu); K.E.M. and R.H. (Hbo); M.Laslo and J.H. (Eco) collected frogs. R.M.H. (Xtr); M.G.P., H.S.P. (Epu); and D.R.B. (Eco) collected tissue samples. A.B.M., D.R.B. (Eco); J.B.L. and I.P. (Xtr) extracted DNA. A.B.M., S.M.R. (Epu); K.E.M., R.H. (Hbo); and L.M.S. (Eco) extracted RNA and libraries were prepared by A.B.M. (Epu). M.Laslo, J.H. (Eco); K.E.M. and R.H. (Hbo) provided RNA-seq data. T.K., M.J.R., J.B.W. (Epu); and J.B.L. (Xtr) coordinated sequencing. C.P., J.G. and J.S. prepared and Publishers note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional afliations. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the articles Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the articles Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/ licenses/by/4.0/. The Author(s) 2024 1 Department of Molecular and Cell Biology, Weill Hall, University of California, Berkeley, CA 94720, USA. 2DOE-Joint Genome Institute, 1 Cyclotron Road, Berkeley, CA 94720, USA. 3Department of Biochemistry, Stanford University School of Medicine, 279 Campus Drive, Beckman Center 409, Stanford, CA 94305-5307, USA. 4Computer Science Division, University of California Berkeley, 2626 Hearst Avenue, Berkeley, CA 94720, USA. 5HudsonAlpha Genome Sequencing Center, HudsonAlpha Institute for Biotechnology, Huntsville, AL 35806, USA. 6Pediatric Genomics Discovery Program, Departments of Pediatrics and Genetics, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA. 7Department of Organismic and Evolutionary Biology, and Museum of Comparative Zoology, Harvard University, Cambridge, MA 02138, USA. 8Dpartement Adaptation du Vivant, UMR 7221 CNRS, Musum National dHistoire Naturelle, Paris, France. 9Department of Biological Sciences, University of Cincinnati, Cincinnati, OH, USA. 10Department of Biomedical Engineering, Ulsan National Institute of Science and Technology, Ulsan 44919, Republic of Korea. 11Center for Genomic Integrity, Institute for Basic Science (IBS), Ulsan 44919, Republic of Korea. 12Department of Integrative Biology, Patterson Labs, 2401 Speedway, University of Texas, Austin, TX 78712, USA. 13Department of Biological Sciences, University of the Pacic, 3601 Pacic Avenue, Stockton, CA 95211, USA. 14Department of Molecular and Cell Biology and Institute of Systems Genomics, University of Connecticut, 181 Auditorium Road, Unit 3197, Storrs, CT 06269, USA. 15Department of Molecular Biosciences, Patterson Labs, 2401 Speedway, The University of Texas at Austin, Austin, TX 78712, USA. 16Innovative Genomics Institute, University of California, Berkeley, CA 94720, USA. 17Chan-Zuckerberg BioHub, 499 Illinois Street, San Francisco, CA 94158, USA. 18Okinawa Institute of Science and Technology Graduate University, Onna, Okinawa 9040495, Japan. 19These authors contributed equally: Jessen V. Bredeson, Austin B. Mudd, Soa Medina-Ruiz. e-mail: dsrokhsar@gmail.com Nature Communications | (2024)15:579 18  ...

... Indiana Audubon Society NEWSLETTER FEB.MARCH 2024 Vol.55, No.1 CLAY-COLORED SPARROW DISCOVERY Indiana's first confirmed breeding record A LOWER 48 BIG YEAR A Hoosier professor's 2023 sabbatical adventure MEMBERSHIP PERKS Electronic bi-monthly & quarterly newsletters Mailed copies of bi-monthly & quarterly newsletters Access to Cornell Lab's Birds of the World ($49/yr. value) Early registration to Indiana Dunes Birding Festival Discounted Field Trips & Programs Special Access to Mary Gray Birding Sanctuary 15% discount on all IAS online store merchandise Register a friend to any IAS field trip at member rate 0 UPCOMING Join Indiana Audubon for an assortment of field trips and workshops being offered this summer and early fall. Visit indianaaudubon.org/events for more information or to register for any of these upcoming activities. Additional events are listed on our website, and many fill early! Register online today. FEB. 13: Feathered Focus: Bird Safe Indy [Virtual, Zoom] FEB. 16: Tropical Birding Live from Amagusa Reserve, Ecuador [Virtual, Zoom] FEB. 23: Hoosier Birders' Hour: Feeding Backyard Birds [Virtual, Zoom] Clay-colored Sparrow by Ryan Sanderson MARCH 12: Feathered Focus: The Secret to Attracting Birds [Virtual, Zoom] MARCH 16: Flock & Learn: Waterfowl Walk at Eagle Creek Park [Indianapolis] MARCH 16: Summit Lake Spring Waterfowl Trip [New Castle] MARCH 16: "What's That Waterfowl?" Young Birders Walk [Indianapolis] MARCH 23: Kankakee Ducks and More Early Spring Birding [North Judson] MARCH 26: Indiana Birding: Crash Course [Virtual, Zoom] 1 CARDINAL | INDIANA AUDUBON SOCIETY BN EG LL Be a part of Indiana Audubon! Sign up at: Indianaaudubon.org/membership TRIPS & EVENTS On the cover: E S TU S RK S 3 -1 UD E ST AG PA A BE T/I Y EN HI RS NE RA RT LI B CL CO EX 8 O R C O RY P W I TH PE $1 0 R W ITH IFE ME 0 IA S BE & ES IV E$ 7 A 75 L ILE AL E P R IN IV DE $2 NT ND YO UB S C G L R B E RD FA TR Y B E JO 0 $1 0 0 $5 FIT G NE K C T TI N O OC N E IBU 0 LY FL MI $4 E F A CO EN N TH ILY N UP FA M SIG US 0 LT $3 R 1 AD U FO I DU FIT AL S NE BE DIV TODAY LI F The Cardinal Newsletter is a bi-monthly publication of the Indiana Audubon Society. Its purpose is to share stories and conversations so that members and the birding community beyond can stay meaningfully connected both to birds and to the people dedicated to their protection. RENEW CA Contributors Leah Baker David Benson Wesley Homoya Joni James Libby Keyes Theresa Murray Ryan Sanderson Kristin Stratton OR SIC Editor & Graphic Designer Whitney Yoerger JOIN IN Executive Director Brad Bumgardner BA Production Team NEWS INDIANA AUDUBON SOCIE T Y W E'R E H I R I N G! Indiana Audubon is in search of a dedicated individual to become part of our staff as the Development and Engagement Manager. This role is crucial for advancing Indiana Audubons mission and involves actively contributing to fundraising and development initiatives, ensuring the ongoing success of our conservation, education, and research programs and initiatives. The job posting will be open until Feb. 15 or until the position is filled. Apply today! Get the details at indianaaudubon. org/currentopenings or scan the QR code. Trout-lily at Mary Gray Bird Sanctuary by Libby Keyes. The Sanctuary entrance by Libby Keyes. H E A LTH Y H I K I N G I N 2024 This year, immerse yourself in nature and improved well-being by exploring the 8 miles of trails at Mary Gray Bird Sanctuary in Connersville. Delight in the emotional and physical benefits of the sanctuary as you aim to cover a minimum of 25 miles there this year. Relish the peace, encounter birds and other wildlife, and experience this Fayette County gem while walking, hiking, or running on the trails. Interested in joining the MGBS Healthy Hiking Challenge? The sanctuary welcomes visitors from sunrise to sunset every day of the year. And feel free to bring your family and friends along for the adventure. Trail maps are available at the kiosk near the shelter across from the centralized parking lot. While there is no entrance fee to visit, donations are welcome and will help keep the sanctuary open to all visitors throughout the years to come. The sanctuary is not a state park, receives no federal or state funding. Visitor and member donations help keep the Sanctuary the beautiful place that it is. Take your first step by downloading the MGBS Healthy Hiking Challenge Entry Form at indianaaudubon.org/hike. FEB. MARCH 2024 2 NEWS INDIANA AUDUBON SOCIE T Y PR E PA R E FO R TH E D U N E S B I R D I N G FE S TI VA L Get ready for an even bigger and better Indiana Dunes Birding Festival, taking place from May 16-19! Featuring an exciting lineup of over 180 field trips, programs, and workshops, our festival schedule promises an exhilarating birding experience. Explore the full schedule and plan your festival activities in advance. Easily peruse the schedule or access the guidebook PDF online. New this year, Indiana Audubon members must renew their membership by midnight on Feb. 28 to secure early access to festival registration. Priority registration for Indiana Audubon members begins at 10 a.m. Central Time on March 1. Secure your spot for the four-day event at just $65, with options available for youth and single-day participation. We look forward to celebrating the festival's 10th anniversary with you! Make your festival plans, mark your calendar for priority registration on March 1, and renew your membership by midnight on Feb. 28. View the schedule at indunesbirdingfestival.com/pages/schedule or scan the QR code on the right. B R I DG I N G V I S I O N A N D AC TI O N Indiana Audubon's annual winter retreat, held from January 12 to 14 in Rockville, proved to be a productive weekend for the IAS Board of Directors. Despite the freezing temperatures, the board engaged in fruitful planning sessions, outlining the path for numerous exciting programs, committee tasks, and initiatives at Mary Gray Bird Sanctuary and for the organization as a whole, ensuring a promising and eventful 2024. Board members also took moments to enjoy birding from the windows. A sincere THANK YOU goes to our dedicated Board of Directors and staff, whose commitment made this weekend especially impactful. 3 CARDINAL | INDIANA AUDUBON SOCIETY Grant Report B E THAN Y L AN D I N STITUTE BY THERESA MURR AY On April 9, 2022, the Avian Conservation Uganda Society (ACUS) visited Bethany Land Institute (BLI) in Luwero District, Uganda, as part of a pilot program. Dedicated to promoting bird conservation in Uganda, ACUS collaborates with organizations like BLI to advocate for the preservation of birds, habitats, and ecological assets. Established in 2022, ACUS is the largest dedicated regional bird society in East Africa. Following their visit to BLI, ACUS recommended capacity building for site guides at the institute through the provision of birding education materials, such as guidebooks and binoculars. Given than BLI USA is headquartered in Indiana, we found a partnership with Indiana Audubon and were the grateful recipients of a 2022 Mumford & Keller Grants and Scholarship Program award. This grant facilitated the purchase of 12 sets of Gosky 10x42 Roof Prism HD binoculars for Lazarus' Forest Conservation. BLI Uganda, inspired by Pope Francis' encyclical Laudato S, addresses environmental degradation through a new integrated educational program for a lifestyle change through education and experience. Lazarus' Forest serves as a unique educational center, allowing experiential learning about conservation, integrated ecosystems, and wildlife. BLI welcomes visitors for guided tours and overnight stays, providing a chance to explore the forest's flora, fauna, and birdlife. Early this year, I personally delivered the binoculars to BLI in Uganda. What I found on this trip both surprised and delighted me. My first stop was at the home and guesthouse of one of our founders, Fr. Emmanuel Katongole. The guesthouse sits adjacent to the Entebbe Zoo, where birds are free to fly around the area and over adjoining Lake Victoria. I shared the binoculars with him and his staff to explore a bit. Most of them had never seen binoculars before, including his aunt who is well into her 80s. They were in awe of the birds, flora, and even the moon through the binoculars! It was a heart-warming experience. On to the BLI campus the next day, I delivered the binoculars to our resident Forester and Taxonomist, Chris Mukwaya, who promptly catalogued them into the Institutes inventory. The next day Chris led a class on how to use the binoculars. Our students come from the poor rural areas nearby, and struggle to pay even basic school fees. Equipment such as binoculars are non-existent. Chris led off with basic instructions on how to assemble, care and use them. He emphasized that they were important equipment in conservation, and with his wry sense of humor told the students should they break them, their father would have to sell a cow to buy new ones. The point was made the students take great care with the equipment. They were taught how to move through the forest quietly so as to not disturb the birds. And then they were off, with the assignment to find 3 common bird species, and bring back MUMFORD & KELLER HIGHLIGHT photos of birds he had not listed, using the cell phone adaptors. (Yes, the students have basic cell phones with photo capabilities, but no wifi or smartphones.) One hour later, they returned, assignments successfully completed, followed by a discussion on the varying bird species they discovered. The binoculars are integrated into the curriculum as part of the Forestry Management & Ecological Protection Cycles. In 2022, ACUS identified 100 bird species in BLI's forest, a number that has since risen to 161. The students are enjoying birdwatching and have created their own club and their theme is "their life is our life." We are in the process of building the Lazarus Forest Information Center an ecological and information center at the entrance to our 300 acre forest. From here, students and tourists check out the binoculars for a small fee to explore the forest. To date, we have had a few tourists, and word is spreading, as I even had an inquiry from a US Audubon Society member who had heard about us and wanted to visit! Interns and students from Wheaton College, the University of Notre Dame, and Duke University visited this summer and had in- depth classes in ecological and forest preservation using the binoculars. To sustain life on a healthy planet, interconnected ecosystems must be protected. Uganda, known as the "Pearl of Africa," is rich in biodiversity, ranking second richest for mammals in Africa, second for birds in Africa, and seventh for higher plant species in the world. BLI, Indiana Audubon, and similar partnerships worldwide exemplify how conservation efforts can transcend borders. We are proud to work together in appreciation of the beauty that surrounds us. We invite you to follow our progress on our website (bethanylandinstitute.org) and social media channels, as we continue restoring the ecosystem and educating our students and visitors on the care of our common home. We also invite you to visit us in Uganda, for what we promise to be an enriching experience, for both the visitor and our campus staff and students. Editor's Note: This report has been edited for length and clarity. FEB. MARCH 2024 4 FIE LD NOTES FRO M A NATU R A LIST By Joni James Nature journaling involves using words, pictures, and numbers to record your observations, connections, and experiences with nature on paper. It is not about being an artist. Observation, curiosity, and creativity are skills that you can develop. There is no wrong way to do it just have fun! Questions about this series or nature journaling? Email Joni at heronwatch0@gmail.com. 5 CARDINAL | INDIANA AUDUBON SOCIETY Collaborative Efforts R E S U LT I N AN Indiana First BY KRIS TIN S TR AT TON On June 17, 2023, The Dunes-Calumet Audubon hosted a field trip led by Julie Bonnema, with experienced birders Angie Archer and me, among the fifteen participants. It was a beautiful day for birding, filled with old and new birding friends. The day at Kankakee Sands offered perfect weather, with clear skies, a slight breeze, and temperatures in the low 70s. Julie had a few key locations in mind, each with target birds for the group to observe. Along the way, we encountered some little surprisestwo of those being at the corner of where units F, D, G and the Beaver Lake Nature Preserve meet. We stopped there to look and listen for Blue Grosbeaks. I ventured away from the group to unit G to scan and listen while Julie stayed by units F and D to do the same. Upon scanning the restored grassland prairie habitat, managed by The Nature Conservancy, Julie came across a late Clay-colored Sparrow. She called me and Angie over to see it and confirm the identification, saying, Kristin knows these well." As I was walking over, I heard the raspy buzzzz buzzzz call and confirmed that it was indeed a Clay-colored Sparrow. I snapped one photo of the bird perched with food. Julie, Angie, and I all assisted in helping the field trip attendees see the bird. We were excited because it was mid-June and Clay-colored Sparrows are migrants in Indiana, and spring migration had been over for a few weeks. As we were observing the sparrow perched with a tiny inchworm in its bill, we heard a second buzzzz buzzzz call come from the west of unit F. Two Clay-colored Sparrows! That, in itself, is a treat. We spent a considerable amount of time observing the birds and their behavior. The first bird was perched in the same spot with food, flying down to the same location four times. Julie also witnessed the bird carrying food to the same spot multiple times. Both birds were singing and doing their chip calls. At one point, Julie saw one fly away, and the other arrived with food at the same spot. Angie kept all our eBird checklists that day and logged the Clay-colored Sparrows as breeding birds. At this time, I dont think any of us had realized that we had discovered the first breeding Clay-colored Sparrows in Indiana. We needed to get the trip moving along and also didnt want to spend too much time at that spot as to disturb the sparrows. (By the way, we never heard or saw Blue Grosbeaks that day.) On our way to our next spot, we had to abruptly stop for a singing Connecticut Warbler, also a late migrant. That's a whole different story for another time. REMARKABLE RECORDS I consulted with Jeff McCoy about our observations of Connecticut Warbler and Clay-colored Sparrow, inquiring if either bird breeds in Indiana. Jeff confirmed that both species were considered late. He also indicated that breeding Clay-colored Sparrows had never been confirmed in Indiana. Upon sharing this information with Julie and Angie, we decided we had better do some more observations. The next morning, Julie and I returned to do a mini "big sit, but strong south winds altered the weather, keeping all the birds hunkered down and quiet. Despite spending four hours watching and waiting for Clay-colored Sparrow activity, we only heard one buzzzz buzzzz song and observed a single sparrow popping up from unit D, flying over and perching in a tree along the road. A few weeks later, Brad Bumgardner let us know that he had consulted with Allisyn-Marie Gillet and Ken Brock regarding our observations. He clarified that, according to the Breeding Bird Atlas protocol, a bird carrying food is considered a confirmed breeding record. Dr. Brock provided additional context, citing four other summer records in Indiana, including a pair in June 2016 at Kankakee Sands Unit D. Other records include a territorial Clay-colored Sparrow in St. Joseph County in July 1989, Pigeon River Fish and Wildlife Area in June 2011, and again in St. Joseph County in June 2013. So, on June 17, 2023, Julie, Angie, and I collectively had a hand, eye, and ear in finding the first confirmed breeding Clay-colored Sparrow in Indiana. The Clay-colored Sparrow and Connecticut Warbler sightings came at a time when I lacked confidence, especially in birding. Some great memories happened on that field trip that I will always hold near and dear to my heart. The birds, fellow trip participants, and those we consulted with served as a reminder to stay positive, be mindful, have confidence in aspects of life. This experience reignited my passion for sharing my birding knowledge with others. Caught in Action: Kristin Stratton swiftly snapped this photo of the Claycolored Sparrow carrying food, confirming the breeding sighting. FEB. MARCH 2024 6 SABBATICAL WELL-SPENT THE THRILLS OF A LOWER 48 BIG YEAR BY DAVID BENSON T heres no way we are going to find this thing. I was sure of it. The trails were packed with tourists, hiking noisily all over the mountain side, completely oblivious to the possibility of a Sooty Grouseand that there was such a thing as a Sooty Grouse. Lets just keep scanning, my friend, Maikel Wise, who joined me on this western trip to Rainier, Washington, and the Pacific coast, suggested. So, we continued scanning the heath subshrubs. Even at a distance, Ive got a decent shot at picking one out. Ive been doing research on ptarmigan in Glacier National Park, Montana, for decades and have a pretty good search image for grouse. However, my internal clock was telling me that we needed to cut our losses and move on. We spent way too much time in Seattle traffic yesterday and needed to get to the coast where the majority of my target species were. Sooty was the only species I needed in Rainier. On the other hand, it would be a lifer I cant give up too easily! Keep searching Got it! Maikel exclaimed. Wait, is that a grouse or a ptarmigan? Maikel had found the bird in the deep 7 CARDINAL | INDIANA AUDUBON SOCIETY willows, but not too far from the trail. Getting it in my binoculars, I said, Thats no ptarmy! Its a Sooty! Yes! #468 for the year, and one that I was definitely not guaranteed to get. Im a biology professor at Marian University in Indianapolis. I decided to do this big year in early March 2023 when I was granted a sabbatical for the fall. This gave me freedom for a few more fall trips than I would be able to do with my typical class schedule. My travels fit the times I had available. Spring break I went to northern Florida and south Georgia, adding 80 species to the year. Then, in early May I went to Utah to watch my middle daughter graduate from Westminster College. I went a day early so I could bird, adding 32 species. From there, I flew straight to Arizona, primarily birding in the Madera Canyon and the Portal areas for a week. There, I added 90 species and had so much fun. Everyone there is a birder, so if you are missing a target, just ask. I asked about Spotted Owl and was told the exact tree it would be sitting in during the day, along with Red-faced and Olive Warblers and Mexican Chickadees singing nearby. Returning to Indiana during the peak of spring migration and doing my required guide to go for the heron on private property south of the border wall, and he graciously invited me, along with Katey Powell and Kyle Wiktor. This was the highlight of the trip with fantastic views of some of the rarest of the rare, like the heron (#600 for the year), Brown Jays (so big that at first glance, I thought they were hawks), Morelets Seedeaters, Red-billed Pigeons, and Rose-throated Becards. Texas yielded 36 new birds for the year leaving me at 611 for the lower 48. Among the 611 species I saw in 2023, 75 were entirely new to me. Which was my favorite? For me, often its the chase more than the bird itself that endears me to it. For example, the Black Rosy-Finch is a beautiful bird on its own. But, the fact that I had to search along the Beartooth Highway, a 11,000-foot high stretch of road in the spectacular mountains just outside of Yellowstone National Park, made this species my favorite of the year. I searched and searched with mind-blowing views in all directions, and when dusk was falling and Id almost given up hope, I heard one calling outside the car window. A brief hunt located three individuals among the alpine rocks, species #446 for the year. Over the course of the year, I learned an enormous amount, working hard on tricky identifications, better understanding birds' movements, and simply grasping at a more visceral level bird ecology, which I will be able to pass on to my Marian University students. This crazy goal was the driving, fun force in my life last year, and I highly recommend it! David Benson, Ph.D., is Marian University's senior biology professor. He finished 2023 on a high note, ranking 12th for identifying an outstanding 611 bird species across America's Lower 48 states during the 2023 calendar year. Great Gray Owl (left) and White-tailed Ptarmigan (right). David Benson annual (carbon neutral) birdathon for the Amos Butler Audubon Society with Wesley Homoya resulted in an additional 50 new species. During my Montana summer I was able to bird in Glacier, of course, but also take day trips a few times around Montana, seeing lots of amazing views, habitats, and birds, and adding 70 species. Because I was already close by, I decided to go straight from Montana to Washington state in mid-September, then take a week in California, mostly in the San Francisco and Los Angeles areas, where I took a second pelagic trip. The first was off Cape Hatteras in May, adding 8 species. This one was out of Half Moon Bay and was super productive. Even though I had spent a lot of effort trying to learn the species that were most common, brown and white birds zipping by the bouncing boat at great speed take practice to identify in the field. Thankfully, pelagic tours include expert spotters on board. All told, the Washington and California trip added 73 species. In October, my wife Kara and I traveled to south Florida and the Keys, including Dry Tortugas National Park, to celebrate our 30th anniversary. Despite not being a birder, she enjoyed the thrill of adding to the burgeoning year list, bumping it from 542 to 560. Who wouldnt enjoy joining the experts at the Florida Keys Hawkwatch, seeing hundreds of peregrine falcons along with my targets, Short-tailed Hawk and Mississippi Kite? Thanksgiving found my family in North Carolina with friends. After that, I dropped off the rest of the family at the airport and drove overnight to Cape Cod, spending hours on cold, windy beaches looking, unsuccessfully, for Dovekie and Manx Shearwaters. I loved it, and I found Great Shearwater, Razorbills, and eiders, plus 10 other new species along the Massachusetts and southern Maine coasts. The last best trip of the year was to Texas, where, thanks to Jeremiah Oden, the Bare-throated TigerHeron awaited. Jeremiah had already booked the FEB.MARCH 2024 8 Q T ELL US A LIT TLE ABOUT YOURSELF. FAMILY? WHERE DO YOU LIVE AND WORK? Photo courtesy of Leah Baker I recently moved from Franklin, Indiana, to a cabin in the woods in Nashville, Indiana. I live here with my husband of almost 12 years and a senior brown tabby cat who showed up on our porch shortly after we moved. I have worked for the Indiana State Bar Association since 2017. We shifted to about 75% remote work after the pandemic, allowing me to spend most days working near my feeders and the mature trees that surround our property. I started painting birds and other fauna in 2020. Currently, I am selling some of my work and have recently been accepted to showcase it at B3 Gallery in Nashville. I hope to someday teach a class about nature journaling to inspire people to explore the natural world through creativity. Additionally, I enjoy traveling, backpack camping, and hiking. Q W HAT GOT YOU INTERES TED IN BIRDS AND BIRDING? meet a MEMBER LEAH BAKER In my early twenties, a close friend passed away unexpectedly and tragically. I remained close to his family, and his father was using some Native American rituals and lore to navigate the grieving process. Through this, he mentioned that his sons guardian was a red-tailed hawk. Naturally, I started seeing Red-tailed Hawks everywhere. This led me to actively look for them, observing their habits, and, of course, making observations of other species. Before long, my husband purchased my first birding book and a Vortex monocular. I was captivated and delighted by every new species. Eventually, after watching me take photos with my phone and monocular, my husband also gifted me a Sony a6000, and I slowly began documenting in a more intentional way. Q W HAT INSPIRED YOU TO INCORPOR ATE BIRDS INTO YOUR AR T WORK? Like many, I felt like I was losing my mind during the early days of the pandemic. Everything was shrouded in uncertainty, and it was very isolating. I needed something to occupy my time. Im not sure what possessed me to take up painting, but in short order, I enrolled in a fabulous online course with the amazing artist Liz Clayton Fuller through Cornell Lab. The topic was nature journaling. Over the next few months, I took as many courses on painting or natural journaling as I could find, and eventually, the training wheels came off. I started painting birds and nature journaling on my own. Essentially, I said, how else can I bird? And the answer was through artistic study. To me, it's another way to explore anatomy, appearance, behaviors, etc. Painting was my sourdough. Q W HAT'S YOUR FAVORITE BIRDING DES TINATION, BOTH IN INDIANA AND OUTSIDE THE S TATE? In Indiana, I like birding hotspots that are off the beaten path. I prefer land trusts because they are usually less crowded. Beanblossom Bottoms is my current favorite. I love the variety that wetlands bring. Outside of Indiana, one of my all-time favorite birding destinations is Point Lobos in California. Bird Island houses a huge colony of cormorants, and Blackcrowned Night Herons nest in the cliffs. Peregrines and Osprey soar. Oystercatchers, guillemot, Brown Pelicans, quail... it is truly extraordinary where the land meets the sea. Q D O YOU HAVE A FAVORITE BIRD OR GROUP OF BIRDS? Raptors have always been my favorite. There is something that is just mesmerizing about their piercing eyes, their athleticism, and their resilience. My current favorite bird is the Eastern Screech-Owl. I was lucky to have a nesting family visit my yard each year when I lived in Franklin. It brought me so much joy to observe them each year. 9 CARDINAL | INDIANA AUDUBON SOCIETY Resplendent Quetzal by Francesco Veronesi/Wikimedia Commons February 1-10, 2025 Join Indiana Audubon for an exciting birding adventure in Guatemala, the northernmost country in Central America. Discover the countrys rich avian diversity with nearly 750 bird species, including 35 Mesoamerican endemics. From lowland rainforests to high-elevation cloud forests, explore Guatemalas stunning landscapes featuring volcanoes, lakes, Mayan culture, and ancient ruins. This tour takes you through misty cloud forests, colonial Antigua, and offers glimpses of specialty bird species like the Horned Guan, Resplendent Quetzal, and the captivating Pink-headed Warbler. Dont miss this spectacular trip to one of Central Americas most diverse nations! El Quetzal boat by Wesley Homoya INCLUDED IN THE TOUR EXPERIENCE: IAS leader and guide coordinating trip logistics before and during the tour, LEARN MORE Lake Atitlan by Luk Janika/Pixabay Guatemala: Go Birding In the Shadow of Volcanoes including all eBird checklist submissions. Specialized Natural Selections Driver and local guides. Transportation with fuel included. All lodging for 10 days, 9 nights in listed hotels. All meals, beginning with dinner on day 1 and ending with breakfast on day 10. All entrance fees to reserves and national parks. This tour is organized by Indiana Audubon in partnership with Natural Selections Tours. Resort by Wesley Homoya $4,538.00 per person $250 Single supplement Wine-throated Hummingbird by Wesley Homoya INDIANA AUDUBON SOCIETY ADVERTISE IN THE CARDINAL For more information about The Cardinal and advertising rates, visit indianaaudubon.org/the-cardinal.  ...

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