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... How Humans Show Up in Human Service Roles ______________________________ 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 ______________________________ by Jennifer M. Peters-Reece May 2024  Copyright by Jennifer M. Peters-Reece All Rights Reserved May 2024 Abstract The United States is experiencing a paradox related to the care and support of individuals with developmental and intellectual disabilities. As diagnoses of these disabilities increase, there are not enough people to provide the supportive care needed. As an alternative to researching turnover for human service professionals, this study investigated why human service professionals choose to stay in these demanding roles. Using a phenomenological approach, human service professionals in a large, midwestern, nonprofit developmental disability services organization participated in an investigation of their lived experiences. This action research paper explored the experiences of longer tenured employees, as well as new employees entering the system, and the decisions that led to them to stay with the organization. With an emphasis on the first hundred days of employment, an intervention was created to influence elements of retention. Participants then evaluated the program and its impact on their retention decisioning process. Data was collected and analyzed via focus groups, follow-up interviews, pre-tests and post-tests using the Work and Meaning Inventory and the Perceived Person Environment Fit Scale. The predominant qualitative theme for all participants was the need for emotional support during disorienting experiences. While quantitative data suggests the intervention did not have a statistically significant impact on the pre-test versus post-test scores, retention was improved by 21.5%. Fred S. Klipsch Educators College Marian University Indianapolis, Indiana APPROVAL OF THE CAPSTONE PROJECT This capstone project, How Humans Show Up in Human Service Roles, has been approved by the Graduate Faculty of the Fred S. Klipsch Educators College in partial fulfillment of the requirements for the degree of Doctor of Education. Dedication Time is a most valuable resource. This capstone is dedicated to the people who forfeited the most time with me so I could achieve a dream. First and foremost, to my daughters, Riley and Reese. It is the joy of my life to be their mom and to have learned such important lessons about humanity and humility through raising them to be women of resilience, brilliance, and courage. Next, it is dedicated to my husband, Brian. His quiet confidence in me pushed me forward day in and day out. To my bonus sons, Jackson and Bryson, Im so grateful that you spent so much time with your dad while I was tucked away researching. Additionally, this project is dedicated to my parents, Jay and Sally Peters, who believed in me long before I ever believed in myself. I love you all so much. Finally, Im grateful to God for the gifts He instilled in me, including the ability to navigate this path. I pray that the experiences I learned through this doctoral program will be used to bless others, according to Gods will. Who knows? Perhaps you were born for such a time as this. Esther 4:14 iv Acknowledgements I am indebted to many people for their support in this project. First, I am grateful to my chair, Jeff Hannah, J.D. Jeffs questions and wonderings made this experience one I will treasure. Second, I am thankful for my committee members, Jeff Kaufman, Ph.D., and Sandra Miller, J.D. Jeff and Sandy were a fantastic support and a wealth of knowledge. Third, I am grateful to Kurt Nelson, Ph.D., who has the dubious task of managing technical systems in an adaptive landscape. Next, I want to thank Kim Schuessler and Sarah Clark, who facilitated the intervention in this work. Kim and Sarahs mindfulness practices, behavioral expertise, and commitment to the humans in human service work made this project better and more personal than I could have thought possible. Finally, I want to thank the human service workers who were involved in this study, as well as those that were outside of the study. Caretaking is not for the faint of heart, but it is certainly a gift of the heart. I am a better person for having studied these difference makers. v TABLE OF CONTENTS Elements Page DEDICATION ............................................................................................................................... iv ACKNOWLEDGEMENTS .............................................................................................................v LIST OF TABLES ........................................................................................................................ vii LIST OF FIGURES ..................................................................................................................... viii CHAPTERS 1. Introduction and Background ..............................................................................................1 2. Diagnostic Work ..................................................................................................................7 3. Intervention Proposal .........................................................................................................35 4. Study Results .....................................................................................................................57 5. Conclusion .......................................................................................................................112 Personal Reflection ..........................................................................................................120 REFERENCES ............................................................................................................................122 APPENDICES .............................................................................................................................136 vi LIST OF TABLES Table Page 1. Summary of Intervention Steps and Timeline ...................................................................53 2. Stage One Participant Codes and Narrative Themes .........................................................58 3. Mentor and Participant Pairing ..........................................................................................74 4. Stage Two Participant Codes and Narrative Themes ........................................................78 5. Stage Three Participant Codes and Narrative Themes ......................................................89 6. Stage Three Mentor Codes and Narrative Themes ............................................................95 7. Work and Meaning Inventory (WAMI) Elements and Descriptors.................................104 8. Participant Retention........................................................................................................109 9. Program Costs ..................................................................................................................111 vii LIST OF FIGURES Figure Page 1. Employee Turnover Decision Process ...............................................................................15 2. Circles of Control ...............................................................................................................76 3. Paired Samples T-Test: Work and Meaning Inventory ...................................................106 4. Paired Samples T-Test: Perceived Person Environment Fit Score ..................................107 5. Paired Samples T-Test: Perceived Person Job Fit Score .................................................107 6. Paired Samples T-Test: Perceived Person Organization Fit Score ..................................108 7. Paired Samples T-Test: Perceived Person Group Fit Score.............................................108 8. Paired Samples T-Test: Perceived Person Supervisor Fit Score .....................................109 viii 1 Chapter 1: Introduction and Background The idea of being too big to fail is one that relates to the financial institutions of the world. Young (2021) explains that in the simplest form, it means the entity is so important that the government would not allow it to go bankrupt because of the seriousness of the economic repercussions. While coined for the financial industry, there are other industries and organizations people rely on that seem to be too big to fail. I work for one. My organization is the largest provider of developmental and intellectual disability services in Indiana. The organizations greatest weakness for years has been attracting and retaining enough human service workers to match the ever-expanding need for services. This capstone process is a glimpse into that system and an attempt at an intervention that might produce progress. The United States is experiencing a paradox relating to the care and support of individuals with developmental and intellectual disabilities. As diagnoses of these disabilities increase, there are not enough people to provide the supportive care needed. The Presidents Committee for People with Intellectual Disabilities (2017) outlined the workforce crisis stating: This currently untenable crisis stems from the following factors: high staff turnover; growing demand for services due to the growth and aging of the U.S. population in general; increased survival rates for people with intellectual disabilities; demographic shifts resulting in fewer people moving into the direct support professional (DSP) workforce; persistently non-competitive aspects of direct support employment, including low wages, poor access to health insurance, and lack of paid time off and other benefits; high stress and demands of direct support employment, including round-the-clock, sevendays-a-week work; insufficient training and preparation for DSP roles; and lack of professional recognition and status for skilled DSPs (p.8). 2 Brief History of Human Services The developmental disabilities industry is a sub-category of the health and human services field. The human service industry has been formally recognized in the United States since the early 1900s. In 1912, President Roosevelts first White House Conference urged the creation of the Childrens Bureau to combat exploitation of children. Several decades later, in 1953, the Cabinet-level Department of Health, Education, and Welfare (HEW) was created under President Eisenhower. With the creation of the Department of Education, in 1980 HEW became the Department of Health and Human Services (Department of Health and Human Services, n.d.). People who enter the human services field as a career do so to meet human needs through a variety of mechanisms, including prevention and remediation of problems, improving quality of life for vulnerable populations, and improving accessibility and accountability among agencies and individuals in service delivery. Human service professionals work in community, residential care, or institutional settings where they provide direct services such as leading a group, providing for activities of daily living, organizing an activity, offering behavior support, or conducting counseling. The National Organization for Human Services (n.d.) describes human services as an umbrella term for clinical, professional, and paraprofessional jobs in diverse settings, including group homes, intellectual and developmental disability centers, community mental health centers, family and child service agencies, and residential treatment facilities, among others. Through the years, the need for human service workers has grown exponentially. St. John (2022) states nearly 600,000 job openings are projected each year over the next decade. The U.S. Bureau of Labor Statistics (2021) projects that employment opportunities for this talent pool will grow by 33% until 2030, significantly faster than the average for all other occupations. Despite 3 growth projections, salaries for human service workers remain low. In the same study, the U.S. Bureau of Labor Statistics noted the median salary for these individuals was $29,889, compared to an average median U.S. salary of $45,760. A major contributing factor to the low wage is that most organizations who employ human service workers take part in a public-private partnership. Most funding comes from the nations public health insurance program for people with lowincome, Medicaid. Because this funding comes from Medicaid, agencies are price-takers, not price-setters. The rate at which they are paid is set by their state through the Medicaid federalstate partnership. In this arrangement, ANCOR (2017) explains service providers lose negotiation power; and most state funding does not consider wage rates in competing occupations. Wages are not commensurate with the responsibility required of the human service workers. Indiana survey data reveals that human service paraprofessional workers are predominantly women. The Indiana FSSA (2018) found the typical direct support professional in Indiana is a 38-year-old single mother, who has been in the field approximately three years. The National Association of Social Workers (2020) reports on professional roles, noting social workers are 90% women, with over 22% of new social workers identifying as Black/African American and 14% identifying as Hispanic/Latino. The human services industry has long been one with low retention and high turnover. ANCOR (2017) reports service providers, particularly employers in the intellectual and developmental disabilities (ID/DD) realms, are contending with external market disruptions which severely impact workforce retention and recruitment, with a national turnover rate in this field of 45%. High turnover impacts the quality of services provided and continuum of care for vulnerable clients, particularly those with ID/DD diagnoses. Families and individuals who 4 receive services report inconsistent support and diminished quality and continuity of care attributed to the employment shortfall. In a state-specific report of human services workforce, Indiana FSSA (2018) notes that approximately 18,000 direct support professionals are employed at Indiana agencies assisting over 40,000 disabled residents. The same report states that on average, providers reported approximately 15% of their positions were vacant. Because of the vacancies, direct support professionals work a significant amount of overtime. The Organization The human services organization being studied is a large, nonprofit organization headquartered in Indianapolis, Indiana. The organization serves 1,500 clients daily with developmental, intellectual, and behavioral disabilities. The overarching goal of the organization is to move individuals with disabilities to a more independent lifestyle. Serving people from two years old to the end of life, the organization offers a continuum of care for individuals and their families. The services provided fall under several categories, including: residential treatment for youth between 6-22; in-home one-on-one support services for children and adults; education via a public charter school and a private academy; behavior management programs; crisis intervention, diagnosis and treatment services for youth; foster care services; community-based, court-ordered supports; medical care; and a variety of autism therapies and treatments offered on the residential treatment campus, as well as in clinics across Central Indiana. Founded in 1967 by families who wanted their disabled children to receive treatment while still having family involvement, the organization has grown into the largest developmental disability services provider in Indiana. With an annual operating budget approaching $100 million, the organizations headquarters sits on its 82-acre residential treatment campus. The organization works closely with the Department of Child Services (DCS) to care for some of the 5 states most abused and neglected children, as well as those with the most profound and pronounced developmental disabilities. The organization is one of the top payees for the states DCS dollars. As a trauma-informed environment, the organization lists innovation, teamwork, positivity, and client-centered treatment among its core values (Internal Document, 2022a). In this 24-7 operation, the frontline staff work directly with clients on goals established with a care team. The organization is accredited by the Council on Accreditation (COA), Commission on Accreditation of Rehabilitation Facilities (CARF), and Behavioral Health Center of Excellence (BHCOE). The Challenge Boiled down, the challenge is there are simply not enough frontline caregivers. The burden of meeting this need is often shouldered by families of disabled individuals, who also carry the economic impact of care (or lack thereof). In their report, the Indiana Behavioral Health Commission (2022) found that untreated mental illness costs Indiana approximately $4.2 billion each year. Researchers observed premature mortality cost Indiana more than $1.4 billion per year, productivity losses were estimated at $885 million, and direct healthcare costs were $708 million. Further, Medicaid costs were $142 million, private insurance costs were $567 million, the Indiana criminal justice system incurred costs of $106 million, there were $566 million in caregiving costs, $407 million in unemployment benefits and an additional $9 million spent through homeless supports in Indiana. Much like the paradox the United States and Indiana, specifically, faces regarding those needing care and those willing to provide it, this organization is at a critical nexus. The waitlist for individuals needing ID/DD services is long and can only be reduced when there are 6 employees available to provide services. Without support from organizations, families without training are left to do the best they can to support their loved one at home. Research from the National Institute of Child Health and Human Development (2021) shows that early intervention results in better outcomes for those with ID/DD diagnoses in physical skills, thinking skills, communication skills, social skills, and emotional skills. Thus, to help face the rising demand for needed services, the organization is increasingly focusing on capacity-building efforts. In a white paper commissioned by the organization, an outside consultant, Ironstrike, LLC (2020) noted the key to building the organizations capacity to serve more people is to attract and retain top talent. In this study, capacity-building was explored from a different lens, particularly how building the emotional capacity of the human service professionals might impact retention. With human service professionals in the ID/DD industry being the focus, I hoped to ascertain the thoughts, opinions, needs and lived experiences of these individuals related to role fit, job satisfaction, and the triggering moments or decisions they make to stay employed at the organization. The goal of the study was to determine the contributing factors for why human service professionals choose to stay employed at the organization, and what supports could be implemented to increase their likelihood of longer tenure at the organization or within the field. The following research questions guided this study: How do human service professionals experience working in the ID/DD environment? In what ways does the Caring for the Caregiver Program influence elements of retention for human service professionals? 7 Chapter 2: Diagnostic Work System Diagnosis The organization measures and reports turnover to the board of directors, providing an annual calculation of the fiscal years results in September. For fiscal year 2021, annual turnover was 41%, followed by 43% in fiscal year 2022 (Internal Document, 2022b), making the retention rate 59% in FY21 and 57% in FY22. This rate is on par with national industry standards. In a 2020 Staff Stability Survey, the National Association of State Directors of Developmental Disabilities Services and the Human Services Research Institute published their survey report of 2,987 providers in 26 states. The combined turnover rate was 43.6% (National Core Indicators, 2020). While the organizations annual retention rate for key care and support positions is aligned with the average within the disability industry, its annual retention rate averages 19-21% below the accepted, desired national average of 78% across all industries, as outlined in a 2019 North America Mercer Turnover Survey (Mercer, 2020). Internal records show that the organization averages 930 employees and 170 open positions, realizing a rolling vacancy of 18%. Last year, the organization started 481 new employees and exited 391 employees, with 42% of those exits being employees with six-months or less of tenure (Internal Document, 2022c). The organization has implemented several technical fixes to provide employee support and encourage engagement and retention over the past several years. Some examples include raising wages for new, client-facing staff by $3.25 per hour from $12.00 to $15.25; creating a free daycare program; increasing tuition reimbursement; providing an annual retention bonus; offering free lunches; providing free legal aid services; enhancing the employee benefits plan; creating a care and concern committee that offers confidential, emergency financial assistance; 8 providing additional training; and offering career advancement coaching. While these extra supports have become standard offerings in the employee experience, these additional benefits have not generated a marked improvement in the retention rate. In fact, the retention rate is lower year-over-year. Further, employees are leaving faster than ever. Whereas employee turnover used to spike in the system closer to six months on the job, employee turnover is now spiking around 99 days. In the initial diagnostic work, informal discussions were held with a dozen human service professionals at the organization. The positions of the people who took part in these one-on-one discussions ranged from management to clinical to front-line direct support professional, encompassing a broad perspective of the organization. From these discussions emerged five agreements or shared values: 1) the work is important and challenging; 2) most enjoyed the work - seeing the larger rewards of helping others; 3) people enjoyed helping the clients or helping others succeed; 4) most staff identified the team as a critical factor in their success, as well as the connection with the clients when they have a tough day; and 5) the majority identified the work they were currently doing as either a calling or a chosen career path. The stakeholders identified below, with their responsibilities and values, completed the initial system diagnosis. Clients and their Families: Most clients, particularly those in residential treatment, are primarily concerned with gaining more independence and moving on from the organization. Those that have active family involvement will work to reunify with family. Those that do not have family involved will move on to a less-restrictive environment, including group homes, foster care, or another agency. Direct Support Professionals (DSPs): These individuals are concerned primarily with the physical health, safety, and behaviors of the clients. They are responsible for the 9 clients activities of daily living and provide support towards gaining more independence. DSPs do not need an education beyond high school and no formal training is required, as the organization provides training through the on-boarding program called New Employee Orientation (NEO). By far, the clients spend most of their time with the DSPs. Frontline Managers: These individuals, who manage DSPs and others, are primarily concerned with clients needs, client safety, compliance, and communication within and to other teams about clients needs. Frontline managers typically get promoted from the DSP career-track: DSP to lead staff to unit manager. A college education is not required, but at least one year of experience working with the client population is a requirement. Clinical Professionals: These individuals are Masters-level therapists who are primarily concerned with the clients mental health, treatment plans, goals, and independence. They work on developing or enhancing behavior-based intervention and management. They have assigned client caseloads based on their areas of expertise (e.g., autism, behavioral diagnoses, sexually acting out, and so forth). Directors and others in Administration: These individuals are primarily concerned with safety, financial stability, and measuring client outcomes. Directors of non-clientfacing teams (e.g., finance, human resources, marketing, etc.) are primarily concerned with career development within the context of the organization. A minimum of a bachelors degree is required for these positions. Executive Team: These individuals are primarily concerned with the health of the organization and the long-term plans for service to more clients. A minimum of a masters degree is required for these positions. 10 Board of Directors: This group of volunteers from the community is primarily concerned with performance and risk management, as well as growth. Funders: Mostly government-backed, funders pay for the care of clients predominantly through the channels of Department of Child Services, Medicaid, Department of Education, and private-pay insurance. Their primary concern is quality care at the lowest reimbursement rate possible. Referral Sources: Most referral sources to the organization are agencies or other child welfare organizations, including the Department of Child Services, Department of Education, and the juvenile justice department. They are primarily concerned with finding the appropriate, safe fit for the client. They ensure oversight of care through providing case workers and treatment team members for each client served by the organization. At a high level, this list summarizes what the stakeholders were looking for. For the purposes of this study, there was not an attempt to further sub-divide these stakeholders into more firmly delineated factions, because of the notion of the study. In compiling the stakeholders for this study, it appeared that the business model of the organization centered its focus on the client. Instead, this study considered if there was another way to frame the work of the organization which would also emphasize focus on the relationship between the client-facing staff and their clients. There is ample research on why people say they leave an organization. In a study of social workers in the Louisiana child welfare sector, Crayton (2021) found that large workloads, long hours, career ladder uncertainty, inadequate training, and supervisor issues were key factors leading to high turnover rates. In another recent study of a major healthcare organization, Ross (2021) analyzed five years of exit data, finding that 11 employees most often cited stress, overwork, and lack of promotion as reasons to leave the organization. In the framing of retention, with enhanced retention being a key goal for the organization, this research focused on why these people chose to stay. What were the internal motivators and drivers that pulled them back to this work and how could these be leveraged to make progress on the organizations biggest challenge? Could extra supports be put into place to help these staff navigate the difficulties and blessings of client care? What would that look like? What does the research say and what theories can be explored to support the individuals who support others? Because the framing of this study was retention, the initial diagnostic work was revisited, as informal discussions were held with additional human service professionals in the organization that had been employed for at least two years. The goal of these discussions was to inform the intervention by hearing more about why these individuals stayed with the organization when they could have left. Four themes emerged from these conversations: Peer support: Discussions with these staff uncovered the peer-to-peer support that is critical to forming early bonds within the organization. One woman spoke of a fellow employee who took me under her wing and helped me learn how to deal with the environment. She noted that while in different roles, the two maintain a close friendship forged through the trauma of the environment. Supervisor belief: While there were mixed reviews regarding on-the-job training, staff spoke of the dichotomy of how supervisors view employees now versus when they were originally hired. A staff shared, I tried to quit three times my first month. My supervisor just kept rejecting my letter of resignation, so I kept coming back. Another said that because of the high turnover rate, supervisors now have to decide if they have the 12 capacity to pour into new staff - navigating a new cost-benefit analysis - the cost of time spent versus the low potential for employee retention. One staff wondered, Why would managers take the time when staff is just going to leave, anyway? I am special: Some staff likened their early days at the organization to boot camp in the military. There was a collective sense that if you made it through the early days, you were more special than those that did not make it. One staff remarked, They used to tell us who they thought would make it and who wouldnt. They were tough, and I liked that. I liked the drill instructor style and that they saw something in me. There is no one else: In making their retention decisions, staff also noted the clients and what might happen to them if the staff left. The thought process was that if they were not there, who would be there for these individuals in need? Would they get the care they needed, or would they be left with disengaged, low-performing staff? It is important to note my deep respect for individuals with ID/DD diagnoses and their families. Any discussion of the stress caused to employees through client experiences or behaviors is done so knowing that these very individuals are on their own treatment path. This was not a study about clients, rather it was a study about those who show up for clients and how they might show up differently. While not a direct goal, and not something covered, it is hoped that client care would improve as the staffs emotional capacity improves. Perhaps this is an area of future research. 13 Literature Review Building emotional capacity, navigating losses, analyzing turnover intention, and exploring the choices human service professionals face at work were at the heart of this study. What draws someone to a role? Why do they stay or leave? What do the wins and losses on the job feel like? Is there a common pain point or a moment that these workers choose role abandonment over commitment? These were the questions at the heart of this studys exploration. Early Theoretical Influences The collection of research on why people are drawn to roles and whether they stay or leave has matured considerably over the past decades. Early study of the topic was released in 1909 by Frank Parsons. An influencer in the vocational guidance movement, Parsons (1909) created the trait and factor theory. The theory holds that the better the fit between the individual and the occupation, the better the persons satisfaction and success. Parsons, whose book on the topic was published posthumously, was the director of the Vocation Bureau and Breadwinners Institute in Boston. In the book he writes, No step in life, unless it may be the choice of husband or wife, is more important than the choice of a vocation (p. 3). Several decades later, Social Psychologist Kurt Lewin proposed that the behavior of an individual in response to a proposed change is a function of group behavior (Lewin, 1947). Any interaction or force affecting the group structure also affects the individuals behavior and capacity to change. Therefore, the group environment, or field, must always be considered in the change process. Parsons 1909 trait-and-factor model and Lewins 1940s field theory work both suggest that when the environment is compatible with the workers personal characteristics and vice versa, positive work experiences are more likely to occur. While both theories present an interesting look at 14 worker behavior, they fail to account for the personality of the individual. John Holland attempted to speak to that in his theory of vocational choice. Speaking to the question of the role of personality, Holland (1959) authored the theory of vocational choice. The theorys core idea was that most people resemble a combination of six personality types: realistic, investigative, artistic, social, enterprising, and conventional (commonly abbreviated with the acronym RIASEC). Each type was characterized by interests, preferred activities, beliefs, abilities, values, and characteristics. Holland concluded individuals search for and enter work environments that permit them to exercise their skills and abilities, express their attitudes and values, and take on agreeable problems and roles (p. 35). This was the early work that would later become Hollands person-environment fit theory. A relatively newer theory, Lent et al. (2002) introduced social-cognitive career theory, which explains how different career development aspects are interrelated. Incorporating concepts from earlier career theories, Lent et al. noted three variables that inform the theory: self-efficacy beliefs, outcome expectations, and goals. Self-efficacy beliefs come from four primary sources of information: personal performance accomplishments, vicarious experiences (e.g., observing similarities to others), social persuasion, and physiological and emotional states. Outcome expectations are beliefs about the consequences or outcomes of performing particular behaviors (e.g., What will happen if I do this?). Personal goals are a persons intentions to engage in a particular activity. In a distilled explanation, this theory says that people are likely to form an interest in an activity when they view themselves as competent at performing it and when they expect the activity to produce valued outcomes. Conversely, interests are unlikely to develop in activities for which people doubt their competence and expect negative outcomes. Interests do not develop when individuals do not form strong self-efficacy and positive outcome beliefs. 15 While explaining the psychology behind why people do what they think they are good at, what this theory does not account for is the variance in self-efficacy within individuals, particularly individuals with a weak sense of self-efficacy. A further critique of this theory is that having a high sense of self-efficacy does not guarantee positive outcomes, because it does not mean that a person has all the resources necessary for success. As social psychology on career fit and choice was maturing throughout the 20th century, so was the research on turnover intention. In his work, Mobley (1977) provided a psychological understanding of the intent to leave a job. Noting the relationship between job satisfaction and turnover intention, Mobley outlined the decisioning process for employee turnover seen in Figure 1. Figure 1: The Employee Turnover Decision Process 16 In labeling the steps, he invited researchers to view turnover as a process and not an event. That process was based on two main variables: job satisfaction and organizational commitment. An alternate theory of turnover developed by Lee et al. (1996) proposed employees follow one of five cognitive pathways when deciding to leave an organization. Deemed the unfolding theory of turnover, the cognitive pathways described how employees interpreted their work environment, identified options, and enacted responses. The first three pathways began with a shock event that somehow jarred the employee. The shock could be personal and positive event (e.g., an employees spouse gets a job in another city), a negative organizational event (e.g., an unfair performance review), or neutral (e.g., an unexpected job offer). The final two pathways did not begin with shock but were characterized by job dissatisfaction. In these two scenarios, the employee either left without another job or with another job. Influencing Factors on Human Service Worker Satisfaction The overarching theme of the theories regarding why people choose roles and how they leave them seems to be that career decisions are complex, multifaceted, personal, and they certainly impact other areas of life. In a study on peoples relations to their work, Wrzesniewski et al. (1997) found that work satisfaction accounted for 20% of the variance of the entire measure of quality of life. This quality-of-life variance prompted an initial focus on the influencing factors of turnover intention and job satisfaction. Surveying the research landscape of voluntary turnover with human service professionals, there were many differing perspectives on influencing factors for both satisfaction and turnover. Further, many approaches to this topic were constrained by their focus, having been framed into stuckness through a narrow, though necessary, approach. Some examples of this framing are explained below. 17 Culture: Cameron and Quinn (2006) recognized that having a supportive organizational culture is correlated to job satisfaction; however, there are several subcultures that can exist within an organization. Reis et al. (2016) identified the subcultures known as clan, adhocracy, hierarchical, and market cultures each have their own characteristics and influencing factors on an organizations outcomes, profitability, productivity, and employee engagement. Exploring these subcultures in her study of 150 service industry employees, Cossey (2022) found that there was no statistically significant relationship between any organizational subculture types and job satisfaction. Personality traits: Michels (2022) investigated the relationship between personality traits and job satisfaction specifically with direct support professionals. Using the fivefactor model personality inventory and a general job satisfaction scale, Michels studied 47 participants in an immediate care facility serving individuals with intellectual disabilities. She found no correlations between the personality factors and job satisfaction. Intrinsic/extrinsic motivators: While direct support professionals personality factors were not correlated to job satisfaction, Krakovich (2018) found when examining intrinsic and extrinsic motivators, a connection emerged. Krakovich studied 27 direct support professionals and their intent to stay in their current role. The direct support professionals cited mostly extrinsic factors for leaving their jobs: financial constraints, benefits they received (or not), and flexibility. The direct support professionals reported staying at their jobs because of intrinsic characteristics, such as relationships with clients and coworkers and their fit between their characteristics and the job. 18 Supervisor competency: Stiffler (2008) investigated whether a correlation existed between the competencies of a supervisor and the commitment/intent to leave for direct support professionals in Kansas. While these professionals viewed their supervisors as having high levels of competence, the study showed that those perceptions had a minimal effect on the overall commitment of the direct support professional. Even where strong relationships with the supervisor existed, those relationships did not impact the commitment of the individual to the organization. Faith-based versus secular values: Hanson (2021) commissioned a comparative study of direct support professionals from faith-based and secular organizations, attempting to determine if there were differences in values, motivations, and co-worker commitments. This study surveyed 100 direct support professionals from a faith-based organization and 87 direct support professionals from a secular organization. Results showed both groups valued relationships, teamwork, and their clients. Interestingly, a spiritual component was not named as a top three motivator in the faith-based organization, but it was in the secular organization. The researcher could not capture a more comprehensive look at the differences, so concluded that most direct support professionals share similar values and concerns no matter their faith background. Organizational identity: Does teamwork make the dream work? Meurer (2022) attempted to find out in his study on organizational identity and influence over employee intention to resign through the lens of social identity theory. Social identity theory says that a persons identity is based on the groups that they belong to. Meurer found that a strong organizational identity correlated with reduced, perceived role conflict and ambiguity. An employee with a strong organizational identification is more likely to 19 experience lower levels of perceived role conflict and role ambiguity. He concluded a company may improve turnover by improving the company identity. Stress, autonomy & recognition: Previous studies in healthcare settings and hospitals found that different factors such as stress, autonomy, and recognition have contributed to turnover. Those factors have not been consistently studied in direct support professionals, so Lugo (2022) created a quantitative analysis of 89 residential facilities. The results indicated that there was no statistical significance between stress, autonomy, recognition, and turnover in residential settings. The study could not establish a connection that these factors were significant precursors to direct support professionals leaving their jobs. Burnout: When looking at the correlation between stress, burnout, and depression among African immigrant direct support professionals (for which the organization in this study has a significant amount), Onyejose (2021) found that stress significantly predicted burnout and depression. Further, job stress predicted burnout and depression in African immigrants working as direct support professionals in the United States. A separate study on burnout by Klaver et al. (2020) found that exposure to challenging client behaviors was associated with burnout symptoms in direct care professionals regardless of nationality. Congruence: Research by Berg et al. (2013) on person-job fit suggests that when employees see more of a fit between themselves and their jobs, they are more likely to experience their work as personally meaningful and respond with enhanced job performance, job satisfaction, and retention. Meaningfulness and calling: More recently, Duffy and Dik (2013) began linking having a job calling to heightened career commitment, maturity, job meaning and satisfaction, 20 and life meaning and satisfaction. This is an area that has so far not been explored directly with human service workers. The Why Behind the Work: Meaningfulness and Calling Much like the organizations stakeholders who have focused primarily on clients and client outcomes, focusing only on why employees leave organizations ignores an important input in employment process: what draws people to the roles they choose in the first place. Interestingly, there is little data available on why individuals choose to work where they work. Nearly 25 years ago, Wrzesniewski et al. (1997) studied peoples relations to their work by looking at 196 employees at two sites with a wide range of occupations. The results showed that most people can easily assign their work role into one of three categories: a job, a career, or a calling. Further, the highest work and life satisfaction was realized by individuals who viewed their work as a calling. The conclusion of that study created the platform for modern-day investigation into work as calling theory and the concept of meaningful work. Berg et al. (2013) defines meaningful work as work that employees believe is significant because it serves an important purpose. One way to measure meaningful work is through the work and meaning inventory (WAMI), which is based on research by Lips-Wiersma and Wright (2012) on meaning in work. The inventory assesses three core components of meaningful work: the degree to which people find their work to have significance and purpose, the contribution work makes to finding broader meaning in life, and the desire and means for ones work to contribute positively to the greater good. As Steger et al. (2012) note, many people desire meaningful work. Their study of 370 employees from a large, western research university indicated that there was a correlation between meaningful work and overall well-being. People engaged in meaningful work appeared to be more satisfied and committed to their work. 21 Meaningful work was also important to workers job satisfaction and contentment in their organizations. People engaged in meaningful work seemed to have characteristics desirable within organizations, namely less risk of turnover, greater commitment, and greater involvement in citizenship behaviors. Duffy et al. (2018) further determined that those living a calling tend to be happiest, most committed, and most engaged employees. What is a calling? Calling is an ancient concept with religious and philosophical roots. As Yama (2018) observed, while there is no universal definition, the current approach is that it consists of three elements: it is experienced through external transcendent summons; it holds a higher purpose of meaning; and serves a prosocial purpose. The fact that there is not a unified definition suggests there is much to learn about meaningfulness and the identification of calling to a profession. Researchers are taking note. White (2018) determined there were 21 studies on calling prior to 2007, and in the past 15 years, there have been over 200 studies. The evidence provided by Duffy et al. (2018) indicates linking calling to work creates an increased sense of meaning and satisfaction with ones career, work, and life. Coyer (2021) estimated that 50% of American workers perceived they had a calling, while 68% of college students believed it applied to their career decision-making. A second, separate study by White (2018) netted similar results, indicating that 43-45% of people feel it is mostly or totally true that they have a calling to a particular kind of work. Initial diagnostic work with the organization in this study suggested similar results, with over half saying they felt called to do the work they were currently doing at the organization. As Banaga (2000) noted in his research, the impact of work on a persons life is huge. His phenomenological study aimed to shed light on the inner world of the person who works instead of the world of work that is out there. He was searching for the meaning that one 22 perceives and brings to work. What he found was that, like many things, the journey of discovering ones calling can take several paths, which only become clear in retrospect - once the person has already arrived. Bunderson and Thompson (2009) discovered in their study of 157 zookeepers across the U.S. and Canada, when viewed as a calling, work assumes both personal and social significance. In that study they found zookeepers believed they were hardwired to work with animals - they were born with gifts and talents that predisposed them to work in animal-related occupations. The zookeepers believed events transpired in some remarkable way to bring them into zoo keeping. They were led or pushed to the right place. This push/pull towards a vocational destiny brought both positive and negative side effects for the zookeepers. From a positive perspective there was a sense of identification, meaning, and importance calling fostered a powerful sense of kinship. From a negative perspective, the zookeepers harbored an unbending duty, endured personal sacrifices, and experienced vigilance in their careers. (p. 39) Berkelaar and Buzzanell (2015) keyed in on the negative aspects of peoples careers when viewed as callings, noting that how people talk about their work matters. They examined five common historically influenced assumptions underlying the contemporary talk about secular (and/or sacred) callings: necessity, agency and control, inequality, temporal continuity, and neoliberal economics. They noted that viewing work as calling may undermine career agency and outcomes by shifting advantages for certain individuals and/or groups by ignoring the societal constraints that are put on some. Berkelaar and Buzzanell were exploring systemic and structural inequalities that created more opportunities for some to explore callings, instead of having to enter the work world out of financial or family obligation. It is a point well taken, particularly for human service professionals who earn a low wage for their work. 23 Even if not identified as a calling, workers feeling that their work is meaningful appears to have added prosocial benefits. Given the passion and drive to work in ones career path, Wilson and Britt (2020) suggest employees with a calling can be an organizations best resource. Zhou (2021) states regardless of how employees find their way into their work, finding work meaningful is fundamental to how employees do everything. As Bunderson and Thompson (2009) conclude, work done solely for profit is unlikely to inspire a sense of significance, purpose, or transcendent meaning. Negative Impacts of Calling and Meaningful Work Identifying work as meaningful and having a calling can increase as well as deplete personal resources at work. Clinton et al. (2017) observed when people believe their work is a calling, it can often be experienced as an intense and consuming passion with significant personal meaning. Studying 193 church ministers, Clinton et al. cited inability to detach psychologically, poorer sleep quality, and decreased energy because of their calling. Their study shed light on how callings may often be challenging, demanding more of people than perhaps less meaningful and less consuming endeavors. As Anastasiadis and Zeyen (2021) point out in their article on the costs of a vocational calling, much of the burden of calling is shouldered not by the called individuals or their employers, but the close family members. They also argued that a calling concept limits a persons ability to exercise choice and self-manage their work-life boundaries. Further, calling introduces the notion of a sacrifice-reliant organization. They argue that organizations with called members have an enhanced duty of care towards the families of its called members. Cardador and Caza (2012) concluded similarly: a calling orientation can lead to increased subjective well-being but may also be a difficult path that leads to high sacrifice, personal strain, and depletion, resulting in lowered subjective well-being. In a study on 24 vocational calling and mental health, Wilson and Britt (2020) found that calling was associated with increased rates of working compulsively and excessively (e.g., workaholism). Those with a calling were at a higher risk for mental health symptoms and work-family conflict because of the physical and psychological absorption of work. As the Berkelaar and Buzzanell (2015) study noted, not only do people now frame their careers as calling, but they now also expect callings to be enacted through careers. Like human service workers, nurses are expected to deliver patient-centered care with empathy and compassion. Patient-centered healthcare is undermined without compassion. Chen et al. (2022) investigated the balance between compassion satisfaction and compassion fatigue in a cross-sectional survey of 336 nurses in China. They found that nurses who worked over 40 hours per week had higher secondary traumatic stress and burnout; nurses who worked longer hours immersed themselves in patients negative emotions; permanent nurses had lower burnout; nurses who served more critically-ill patients had higher compassion satisfaction; and nurses who encountered more nurse-patient conflict events reported higher burnout and secondary traumatic stress. There is a growing body of work that is investigating the impact on trauma workers of working with people who have been traumatized. Cohen and Collens (2013) found the impact of trauma work might increase short-and-long term levels of distress. With symptoms similar to post-traumatic stress disorder, they found secondary traumatic stress can have a significant impact on the workers health. Further, they learned trauma workers have also been found to experience vicarious trauma, meaning personal transformations resulting from a cumulative and empathic engagement with anothers traumatic experiences, which leads to long-term changes. Some trauma workers cope well, and others do not. The workers in their study had both positive 25 and negative challenges that led to a preoccupation with existential questioning to make sense of the world and trying to find meaning in the traumatic experiences. These same researchers concluded organizations should provide a system-level response to facilitating the impact of trauma work on employees (i.e., procedures, support structures, or fostering a culture that recognizes and acknowledges the impact of trauma work on individual practitioners). Staying Power: Job and Person Fit If job satisfaction and work meaningfulness provide frames to understand how individuals make employment decisions, another frame might be explored through zooming out and looking at the collection of forces that influence retention. One attempt at this has been done in the theory of job embeddedness. Job embeddedness theory, as introduced by Mitchell et al. (2001), offers a method of discovering why people stay in an organization. By analyzing the constructs three dimensions (links, fit, and sacrifice) within community and workplace contexts, an overall level of embeddedness is determined and then used to examine retention. As the theory unfolds, it states that embeddedness can be distinguished from turnover in that its emphasis is on the collection of factors that keep an employee on the job, rather than the psychological process one goes through when quitting. The scholars who introduced job embeddedness described the concept having three key components with six overall dimensions: links, fit, and sacrifice between the employee and organization, and links, fit and sacrifice between the employee and the community. In testing the theory with 454 extension agents in Kansas and Kentucky, Young (2012) found that job embeddedness was significantly correlated with and predicted intent to stay at an organization. Introduced earlier, Holland (1996) adds another theory to the discussion with his study of personality and psychological environment fit. His person-environment fit theory says that 26 behavior is a function of the congruence between the individuals personality style and the psychological or social environment. Holland suggests individuals enter environments because of their personalities and remain in those environments because of the reinforcements and satisfactions obtained through the interactions in that environment. Nauta (2010) tested the theory and found that individuals tended to select and enter jobs consistent with their personality types. In addition, evidence suggests that, to some extent, person-environment congruence is related to measures of job satisfaction and stability, job involvement, work quality, productivity, and well-being but not necessarily to measures of decision making, sociability, and problemsolving ability. Developmental Disabilities: A Unique Challenge Human service workers supporting individuals with intellectual and developmental disabilities learn quickly that the role comes with a unique set of challenges. The clients that employees spend their day with can be both a driver to stay in the role and a driver to leave the organization. Part of why the challenge is unique is because of the variety of diagnoses and severity of complications related to the disabilities make for a complex workplace setting. Unlike in a hospital setting, where each person managing patient care has some level of education in the field, no training is required to become a direct support professional, specifically. A comprehensive training program is provided once an employee starts at the organization, but there is no baseline of understanding that all direct support professionals enter the role with. If a new human service worker has never been exposed to disability services, it can be surprising to learn how disability impacts daily functioning. 27 Developmental Disabilities: Definitions and Diagnoses To summarize and further explain the complexity and potential complications of this unique workplace environment, the Centers for Disease Control and Prevention (2022) outlines a common definition for developmental disabilities. Developmental disabilities are a group of conditions caused by an impairment in physical, learning, language, or behavior areas. These conditions begin during the developmental period, may impact day-to-day functioning, and usually last throughout a persons lifetime. As a broad category of conditions, developmental disabilities also include intellectual disabilities. The American Association on Intellectual and Developmental Disabilities (n.d.) defines an intellectual disability as a condition that creates limitations in intellectual capacity and adaptive behavior. Intellectual functioning, or intelligence, is measured to diagnose the condition with resulting diagnosis stemming from a score of 70 or below. To qualify as a developmental or intellectual disability, diagnosis must occur before the age of 22. Intellectual and developmental disabilities are lifelong diagnoses with no cure. Depending on the presentation and profoundness of the disability, many people require significant interventions and supports throughout their life. Autism Spectrum Disorder is classified as a developmental disability. In their Community Report, the Centers for Disease Control and Prevention (2021) published findings from the Autism and Developmental Disabilities Monitoring program. This program monitors Autism Spectrum Disorder (ASD) in eight-year-old children. The results note that ASD diagnosis is on the rise. One in forty-four children were identified with ASD. Among the children identified, boys were over four times as likely to be diagnosed. Approximately onethird of the children diagnosed with ASD also had an intellectual disability. A separate CDC study, the National Health Interview Survey, created Zablotsky, Benjamin et al. (2019) found 28 that approximately 17% of children (one in six) between the ages of 3-17 were diagnosed with a developmental disability. The advocacy and support organization Autism Speaks outlines associated challenges with ASD and related conditions below (Autism Speaks, 2021). 40% of people with autism are nonverbal 31% of children with ASD also have an intellectual disability Half of those with autism wander or elope from safety 28% of children with ASD have self-injurious behaviors, including head banging, arm/hand biting, and skin scratching Associated medical and mental health conditions related to ASD include: o Attention Deficient Hyperactivity Disorder (ADHD) - 30-61% o Anxiety disorders - 11-40% o Depression - 7% of children and 26% of adults o Gastrointestinal disorders - nearly eight times as likely o Epilepsy or seizure disorder - 33% o Schizophrenia - 4-35% o Medication-related obesity - 32% In summary, there is a mismatch between the level of difficulty of the role and the nature of the challenges that are faced by workers trying to support clients. The mismatch is exacerbated by the variety of conditions experienced among and within the clients, and the people in these direct care roles who enter with the lowest formal preparation. 29 Client Care In a review of the literature, Ryan et al. (2021) presented the results on work-related stress and well-being of direct care workers in six themes: challenging behavior; reciprocity; coping and stress; role issues; individual differences; and settings. The researchers concluded occupationally induced stress is an internationally experienced issue in this industry. The challenging behaviors and differences in relationships between staff and their clients, colleagues, and the organization overall created a significant amount of stress. Further, the researchers found workplace demands, lack of agency, and lack of organizational support contributed to higher levels of stress and burnout for direct support professionals. Going deeper, Hensel et al. (2015) looked specifically at aggressive client behaviors and their relationship to emotional exhaustion. In a survey of 671 direct support professionals, they found that while exposure to aggressive client behavior was associated with emotional exhaustion, feeling positively motivated by work moderated the impact of the exposure to aggression on emotional exhaustion. Highly motivated direct support professionals reported lower emotional exhaustion at comparable levels of exposure. Their findings suggest that addressing negative emotional reactions to aggressive behavior is important, but it is also important to foster positivity at work. Klaver et al. (2020) found a direct relationship between exposure to challenging behaviors and increased levels of burnout symptoms in direct care professionals in their study of 1,271 staff supporting individuals with intellectual disabilities. They further found that staff selfefficacy and access to the supervisor/social support system seemed to be factors that influenced staff well-being. 30 Interventions and Research-Based Supports Diagnosing and intervening in the human service worker retention challenge has an important side benefit: the improved quality of care provided to a vulnerable population. In a study of 1,300 people with ID/DD, Friedman (2018) found direct support professional continuity is central to quality of life of people with intellectual and developmental disabilities, including human security, community, relationships, choice, and goals. While the potential interventions are many and varied, research supports focusing on building emotional capacity, offering flexibility, and enhancing training supports to withstand the demands of the job for human services workers. Resilience: In a study of 360 Czech workers in helping professions, Kaprkov et al. (2018) found levels of resilience and perceived job performance were positively associated. Their research indicated resilient workers are healthier and less likely to quit, therefore they recommended assessing resilience when hiring new employees and enhancing the resilience development of current employees. They further found that resilient workers are more satisfied and engaged and have better job performance. Resilience is a malleable phenomenon and is suitable for intervention based on coachingrelated principles, mindfulness, and compassion-based principles or multi-modal cognitive-behavioral techniques. Resilience helps the workers remain engaged despite the stress they experience while working. Stress reduction: Similar to resilience, Loffeld et al. (2022) recommend organizations support resilience by addressing basic needs and motivational factors. In a study on perseverance, they found work-life balance and emotional exhaustion create work stress, while recognition and appreciation were sources of energy and job satisfaction. Work 31 success or achievement was found to be a source of motivation and/or energy. Therefore, they recommended resilience strategies of appreciating positives and maintaining optimism; connecting work to value orientation; reflecting and setting goals; looking for opportunities to learn and grow; investing in relationships that are energizing; and setting professional boundaries. Mindfulness: Mindfulness has been related to enhancing the capacities of individuals to withstand organizational change. In a linear mixed model analysis of mindfulness in forty managers, Mellner et al. (2022) found that the intervention group had a larger decrease in job demands and a smaller decrease in job resources, a larger increase in psychological detachment, work-non-work boundary control, work-life balance, and mindfulness from baseline to post-intervention when compared with the control group. The initial effects were sustained at a 6-month follow-up. Similarly, in a test of mindfulness on the workplace stress of nurses, Clinger (2022) created a six-week mindfulness program. He found that while the sample size was small, the results support existing literature which shows that mindfulness-based stress reduction reduces nursing stress. Burnout reduction: Hagmaier et al. (2013) caution that there can be too much of a good thing. Experiencing a calling is negatively related to burnout, and individuals should be mindful to replenish their personal resources. In their study of 56 human service workers who worked with clients with autism, Manzano-Garcia and Ayala (2017) investigated the specific role of burnout as a mediator in the relationship between psychological capital and psychological well-being. Their findings suggest the need for implementing programs which strengthen each individuals psychological capital in order to prevent burnout and achieve greater psychological well-being. 32 Job Crafting: To enhance person-job fit, employees sometimes implement job crafting. Job crafting is the process of employees redefining and reimagining their job designs in ways that are meaningful to them. Job crafting is based on the belief that roles are malleable. Berg et al. (2013) concluded that job crafting offers a way to understand how jobs are re-engineered from the bottom up by employees. While not all jobs are conducive to job crafting, allowing employees to redefine and reimagine their job designs in personally meaningful ways can influence the overall meaningfulness of the work. Job crafting is a sign of resourcefulness on the job. In a separate study on relational and identity perspectives, Cardador and Caza (2012) found that job flexibility allows individuals to adapt to natural changes in their profession, their own lives, and organizational environments. Training: As Bogenschutz et al. (2015) note, turnover in human service roles has been significant since tracking of the workforce began in the 1980s. One way to intervene in this challenge is to provide competency-based training. Their study suggested that, compared with the control group, direct care professionals receiving a training intervention experienced a significant decrease in annual turnover when multiple factors were controlled. In a later, unrelated study, Wilson and Britt (2020) found that helping fatigued workers after harm has been done is less effective and sustainable than improving the personal and management skills of employees prior to the experience of mental health symptoms. They concluded that training employees on emotion-focused coping and recognizing the negative consequences of working excessively, as well as allowing employees to voice their concerns during organization decision making may mitigate negative outcomes. Wilson and Britts study demonstrates the importance of 33 organizational interventions designed to help employees better respond to stressors in a healthy way. Mentoring: Mentoring is defined as a method of teaching and learning through a deliberate pairing of a more skilled or experienced person with a lesser-skilled or experienced one. The goal of this partnership is to help the mentees feel supported, welcomed, and to support their growth and development in specific competencies. In a review of mentoring programs for nurses in acute care settings, Funderburk (2008) noted several studies that correlated a mentoring program with retention of new nurses, especially novice nurses. Barton et al. (2005) found that 86% of novice nurses attributed the benefits of a mentoring program with helping them feel more comfortable at the patients bedside. Literature Review Summary From the early 1900s to today, researchers have tried to name and claim reasons we choose our work and how it impacts our lives so greatly. Whether our jobs are informed by our personalities, or our behaviors help us choose and stick with (or leave) our roles, Americans have a complex relationship with their vocations. This literature review paints a picture of the employment decision system as a process that is not black and white but is one built upon two key determinants: satisfaction and commitment. As described above, the influencing factors on why people stay in their roles can be internal or external. Internal influencing factors like personjob fit, self-efficacy, belongingness, values, and needs are balanced with external influences like organizational identity, supervisor competency, relationships, and on-the-job benefits. While theorists do not agree entirely on why people stay in their roles, agreement exists across the 34 human services system that leaning into the retention story is necessary to meet current and future treatment needs for people with developmental and intellectual disabilities. In summarizing the diagnostic work, one final assessment is that the sheer number of theories on the subject suggests that this is an area of opportunity for further study from many different frames. Few studies have identified or examined interventions that reduce stress and promote resilience within the human services industry. The balance of this capstone will focus on designing and testing organizational interventions that build individual emotional capacity to foster greater retention specifically for human services organizations. 35 Chapter 3: Intervention On April 12, 1959, then Senator John F. Kennedy provided remarks during the convocation of the United Negro College Fund. In that speech, he said: When written in Chinese, the word crisis is composed of two characters one represents danger, and one represents opportunity. The danger signs are all around us .... along with danger, crisis is represented by opportunity .... So let us raise both our sights and our standards .... In our nations quest for new talent, new ideas, new brainpower, new manpower, no college can escape its responsibility - and no qualified young man or woman can be denied. Irrational barriers and ancient prejudices fall quickly when the question of survival itself is at stake. (Kennedy, 1959, paras. 8, 10, 22) The paradox in the ID/DD industry presented in this study represents, among other things, crisis and opportunity; and a time to focus on new ideas. Thus, the intervention for this study was built upon the adaptive leadership framework: mobilizing people to make progress on their most difficult challenges. The focus was on building an organizational culture that promotes retention, while also developing the individual employees emotional capacity to withstand the work of the organization, including exploring efficacy and agency for those working in client-facing roles. The Phenomenological Conceptual Framework The theoretical framing for this qualitative study was phenomenological. While all research focuses on the phenomenon being studied, Billups (2021) explains phenomenological designs explicitly focuses on the essence of the lived experience, grounded in a shared human condition (p.5). As shared by Creswell and Poth (2018), phenomenological research is influenced by social constructivism theory, which acknowledges the large part that culture plays in an individuals cognitive development. The social constructivism theory is a social theory that 36 highlights the collaborative nature of learning. Specifically, it posits that people in groups construct knowledge for each other, thereby collaboratively creating a shared culture of shared artifacts and meanings. Rooted in philosophy, the phenomenological design aims for a deeper understanding, or essence, of an individuals perspective on the here and now. The sample size is typically 5-25 participants and data collection strategies for this method include: personal interviews, focus groups, questionnaires, reflections, and document reviews (pp. 75-81). As a qualitative study, the emphasis is on the what, how, or why of a particular phenomenon. Greening (2019) describes the critical steps of a phenomenological design, which include bracketing, intuiting, analyzing, and describing. Bracketing is the process where preconceived beliefs or opinions concerning the research topic are identified and suspended. After bracketing, the researcher focuses on the attributed meaning of the phenomenon by immersing themselves in what is being studied. This process is called intuiting. After intuiting, the researcher analyzes the data collected through a coding and categorizing exercise that uncovers themes of significant meanings of the research. Finally, the researcher describes and defines the phenomenon and in so doing communicates with a greater audience the phenomenon experienced. This study was designed to ascertain the thoughts, opinions, concerns, needs, and lived experiences of human service professionals related to job satisfaction, organizational support, and other factors that inform their decisions to stay employed at the organization. The goal of the study was to determine the contributing factors to retention, so that interventions could be explored to improve the retention of new employees. The following research questions guided this study: How do human service professionals experience working in the ID/DD environment? 37 In what ways does the Caring for the Caregiver Program influence elements of retention for human service professionals? Researcher Bias and Bracketing In February 2016, I accepted a role with the organization in this study. Until that time, I had very limited personal experience with individuals with intellectual and developmental disabilities. I recall my initial interactions with the clients in the organization as disorienting and scary. I did not understand how or why someone would choose to work with the population being served because it looked so challenging. It was very hard for me to see past the downsides of the job. I was grateful for the human service professionals who showed up to work with the clients, but I did not understand the willingness to sacrifice personal safety, physical and emotional health for a low wage. Over time, I noticed the positive behaviors and outcomes that were occurring daily. I saw staff and clients engaging in fun outings, laughing, supporting, and living in relationship with each other. The fear faded and my heart broke for the clients in our system who were not only dealing with a disability, but who were also designated CHINS - a child in need of service. A CHIN is someone who is under 18 years old and has been abused or neglected, as documented by the Indiana Department of Child Services. I saw the human service professionals, particularly the direct support professionals, as the lifeline the clients needed to start to trust humanity again. Over the years, I have seen thousands of lives changed for the better - staff and clients alike, including mine. The reverence I have for the client-facing staff and the soft spot I have in my heart for the clients are at the heart of my personal bias in this study. In her book Qualitative Data Collection Tools, Billups (2021) speaks to bias in suggesting, researchers position themselves to make their background known, to disclose their interest in and experience with the research topic, and to acknowledge their connection in 38 order to ensure transparency in the data collection process. (p. 25) She goes on to suggest that data triangulation, bracketing, and prolonged engagement in the field will reduce the researchers voice and enhance that of the research subjects. My role in this qualitative study was to ascertain the thoughts and feelings of the employee population and in so doing uncover themes that contributed to retention/turnover, job satisfaction, and job performance, including any concerns, opinions, and other needs. My role was not to justify any organizational decisions or promise lasting changes to the participants. My study of the phenomenon began with focus groups. I selected a focus group format for three reasons. First, as Billups (2021) notes, focus groups are collaborative interviews designed to capitalize on the groups evolving interaction. Second, this study aligns with the main purpose of a focus group, which Gibbs (1997) says is to draw upon participants attitudes, feelings, beliefs, experiences, and reactions in a way in which would not be feasible using other methods, for example observation, one-to-one interviewing, or questionnaire surveys. Finally, I appreciated that there could be potential benefit to the participants, as well. Gibbs (1997) describes those participant benefits as having the opportunity to be involved in decision-making processes, to be seen as valued experts, and to be given the chance to work collaboratively with researchers, which can be empowering for many. I felt the potential benefits of a focus group outweighed the potential disadvantages. Gibbs (1997) notes the disadvantages could include having challenges with getting a representative sample, as well as focus groups may discourage certain people from participating, for example people who are not very articulate or confident. In that vein, Billups (2021) warns some focus groups suffer from dominant or disruptive personalities who hijack the conversation. She recommends the moderator must be ready to redirect and carefully manage the discussion. Cole (2018) also discusses personality as a 39 potential negative influencing factor in focus groups describing what he calls the introvert effect. The introvert effect says that people with introverted personalities tend to become more introverted in unfamiliar situations, whereas the social dynamic of a focus group encourages individuals with extroverted personalities to speak more often and more vocally, thereby becoming dominators. Cole goes on to advise creating groups that are as homogenous as possible. I acknowledge the focus group format may have increased the volume of extroverted individuals and it might also have reduced the volume of introverted individuals. However, I accounted for that by following Coles suggestion including participants that had two major factors in common workplace and tenure. I do not directly supervise the individuals in intervention; however, my influence as an executive in the organization cannot be ignored. I have known several of the participants for years, so this had the potential to impact their ability to see me as a researcher. Further, during the multiple phases of this study, the potential existed for the participants to be impacted by the Hawthorne effect. Spencer and Mahtani (2021) describe the Hawthorne effect as the phenomenon that occurs when individuals modify an aspect of their behavior in response to their awareness that they are being observed. McCambridge, et. al (2014) identified 19 studies that evaluated the behavior of participants who were aware they were being studied, finding a wide range of variation in the Hawthorne effect. The researchers concluded that research participation can and does influence behavior, at least in some circumstances. To minimize the Hawthorne effect in studies, Cherry (2023) suggests researchers conduct experiments in natural settings, make responses completely anonymous and get familiar with the people in the study. As such, I stressed the need for confidentiality to the participants; assured them that I was assigning 40 pseudonyms; held the sessions in an area away from clients but used frequently for staff meetings; and increased my field time amongst the employees. As previously stated, I have a great reverence for the work that human service professionals do. Hence, in addition to controlling for the Hawthorne effect, I utilized bracketing and data triangulation to attempt to reduce my own bias. Moustakas (1994) describes bracketing as the first step in phenomenological reduction - the process of data analysis in which the researcher sets aside, as much as possible, all preconceived experiences to best understand the experiences of the participants in the study. He cautions this is a difficult task and requires that we allow the phenomenon to be just what it is and to come to know it as it presents itself (p. 86). Utilizing his steps for phenomenological reduction, I bracketed the focus of the research and set other things aside so as to focus on the research questions and process. Then, I implemented horizontalizing - treating each statement as if it has equal value. After that, I clustered the various horizons into themes. Ahern (1999) suggests using a reflexive journal, in which the researcher can log the potential issues that will enhance reflexivity and ability to bracket before, during, and after the research concludes. To enhance bracketing, prior to starting stage one, I began a reflexive journal to identify issues, values, possible areas of role conflict, surprises, or bumps in the process. To triangulate the data, I used focus groups, follow-up interviews, quantitative questionnaires, and field study/observation time during the intervention implementation. I balanced this data with organization documents as available (turnover reports, policies, and procedures), which were also coded to enhance confidentiality. To further reduce researcher bias and misinterpretation, I used the data coding software NVIVO, as well as asked participants to review my interpretations for accuracy. NVIVO was selected because it allows import from 41 multiple sources, it provides transcription service, it offers coding capabilities, and has a userfriendly interface. Participants were given space to tell their stories in a way most comfortable for them, with room for details, examples, and nuanced descriptions. Finally, the additional step of coding participants names helped ensure confidentiality of the study participants. Definition of Terms Autism Spectrum Disorder is a neurological disorder and developmental disability that affects how people interact with others, communicate, learn, and behave. It is commonly referred to as autism. Behavioral disorder refers to a disability that impacts a persons ability to effectively recognize, interpret, control, and express fundamental emotions. Clients are recognized as people who receive services provided to them by the organization. They have a behavioral and/or an intellectual disability and receive a variety of clinical treatments and therapies from the organization, up to and including full-time residential treatment. Culture is the attitudes and behaviors of employees within an organization. Influencers of culture include the environment, policies, procedures, goals, values, and mission. Developmental disabilities are a group of conditions due to an impairment in physical, learning, language, or behavior areas. These conditions begin during the developmental period, may impact day-to-day functioning, and usually last throughout a persons lifetime. Direct support professional is someone who works directly with someone who has an intellectual, behavioral, or developmental disability. They assist clients in reaching their potential, as well as supporting activities of daily living. 42 Employee engagement is the enthusiasm and commitment of employees in the workplace. Human service professionals meet human needs through an interdisciplinary knowledge base, focusing on prevention and remediation of problems, and maintaining a commitment to improving the overall quality of life of specific service populations. Intellectual disability is a condition characterized by significant limitations in both intellectual functioning and adaptive behavior that originates before the age of 22. Retention is an organizations ability to prevent employee turnover. Turnover is the measurement of the number of employees who leave an organization during a specified time. 43 Intervention and Rationale Intervention Description In their book The Practice of Adaptive Leadership: Tools and Tactics for Changing Your Organization and the World, Heifetz et al. (2009) describe adaptive leadership as an iterative process involving three key elements: 1) observing events and patterns around you; 2) interpreting what you are observing while developing multiple hypotheses about what is really going on; and 3) designing interventions based on the observations and interpretations to address the identified adaptive challenge. The proposed intervention in this research was also iterative as the adaptive work was shared amongst the participants. The intervention took place in three stages: STAGE ONE: During the first stage, human service professionals in client-facing roles within the organization were invited to a focus group. The focus group was recorded using a podcast microphone and Adobe audio software. The session was held during business hours in a conference room at a location adjacent to the main campus. This location was free from any oversight by management, as well as any potential client interference. Focus group participants were paid their normal hourly wage for their time, as this focus group occurred during their work hours. Participants were also provided lunch. The purpose of the focus group was to understand how these employees experience working in the ID/DD environment, as well as to inform the specific elements of a Caring for the Caregiver program for new employees that was yet to be developed. The goal was to determine how to make progress on people staying at the organization longer than 90 days (see Appendix F - Focus Group Protocol and Discussion Guide). Using their firsthand experiences and ideas, participants wrestled with the central question: how would we help people stay longer? Krueger (2002) says that researchers should 44 ask open-ended questions, use think back questions, rarely ask why, and avoid dichotomous questions. The focus group questions in this study were developed using this guidance. At the conclusion of the focus group, participants were invited to have a one-on-one, semi-structured interview to delve deeper into any of the content covered during the focus group. Semistructured, follow-up interviews (See Appendix I) were used to clarify the meaning and intention of participants. Holter et al. (2019) describe follow-up interviews as a reflection opportunity, giving both the interviewer and the participant an opportunity to reflect on what was talked about in the first interview, allowing new insights or aspects to emerge. They also give the researcher an opportunity to clarify questions or test interpretations with the participant, thereby enhancing validity. All subsequent one-on-one interviews were held via Zoom. Participants were also invited to help create or review the curriculum for stage two. The data gathered during the first stage, combined with the research findings in the literature review, manifested into the intervention for new employees during stage two. STAGE TWO: During the second stage, the focus turned to the new client-facing employees as the intervention was implemented with everyone entering the system. Each employee who enters the organization does so through a two-week New Employee Orientation program. Termed NEO, it is a time for new employees to learn about the disabilities industry, the organization, and how to care for clients with a variety of disabilities. New employees in NEO are paid their standard hourly wage during this two-week, 80-hour program and are offered daily free lunch, snacks, and beverages. This is an in-person experience led by the Learning & Development team and supported by a variety of special guest speakers, managers, departments, and other staff. NEO classes begin every Monday except for holiday weeks, which are described 45 as weeks that have one of the federally observed holidays. Class sizes vary from as small as oneperson to as large as 40 people. On Day Two of NEO, new employees were informed that the organization was piloting a retention program for client-facing human service professionals called Caring for the Caregiver. While they could opt out at their choosing, these staff were provided extra supports to round out their introductory employment period. The employees then took two assessments: the Work and Meaning Inventory and the Perceived Person-Environment Fit Scale. These assessments functioned as a pre-test for the employees. While all new employees were welcome to take the assessments, only client-facing employees who gave their consent were enrolled in the pilot program. After their assessments were completed, the staff took part in an in-person training that supported building emotional capacity. At the conclusion of the training, each participant was assigned to a peer mentoring group with follow-up meeting instructions, as well as assigned a one-on-one mentor. Upon graduation from NEO, the participants began their on-the-job training. The participants also entered the next phase of the Caring for the Caregiver program - mentoring. Participants met at mutually agreed upon times with a one-on-one mentor twice per month. Participants also met with peer mentor groups, which were comprised of newer and longer tenured staff who met to discuss how things were going for the new staff. These meetings occurred on the main campus in an available conference room, lasted one-hour, and occurred twice per month for three months at 2:00 pm. Snacks were provided. A member of the learning and development team and a behavior management specialist facilitated these groups. Topics and discussion questions for each session were provided in the form of a facilitator guide. Sessions were audio recorded. After participants had been in the peer mentoring program for three 46 months, they retook the Work and Meaning Inventory, as well as the Perceived PersonEnvironment Scale. These tests functioned as the post-tests for the research period. During a seventh, and final, peer mentoring session they moved to stage three of the intervention. STAGE THREE: Stage three became the evaluation stage of the intervention. During this stage, participants were invited to a final focus group (see Appendix G - Focus Group Protocol and Discussion Guide). The goal of this focus group was to determine how the new employees experienced the intervention and whether the Caring for the Caregiver program influenced any elements of retention. The goal for focus groups was 10 participants per group. The focus groups were held during business hours on the main campus in a conference room. Lunch was provided. The sessions were recorded using a podcast microphone and Adobe audio software. Participants received their normal hourly wage during this time. Intervention Tool The Caring for the Caregiver program was the intervention tool. The purpose of the Caring for the Caregiver program was to support the retention efforts of new, client-facing human service professionals within the organization. The program consisted of a pre-test and post-test in the form of two questionnaires (Work and Meaning Inventory and Perceived PersonEnvironment Fit Scale); an in-person training; a Caring for the Caregiver participant guide; a Caring for the Caregiver mentor guide; and a Caring for the Caregiver facilitator guide. Decisions about the content of the Caring for the Caregiver program and the ensuing peer mentoring sessions were informed by existing literature, diagnostic discussions, and the results of the focus group in stage one of the intervention. The Caring for the Caregiver program covered a variety of topics such as building emotional capacity, mentoring, supervisor support, building a network within the system, responding to client needs, self-efficacy exploration, self- 47 care practices to reduce stress and burnout, mindfulness, resilience development, and job crafting techniques. Once the stage one focus group was completed, the Caring for the Caregiver guides were developed with the support of the director of learning and development and a behavior management specialist within the organization. The hope was that the knowledge gained through the program could help with understanding of the lived experiences, thereby helping to increase retention, promote resilience, and increase individual emotional capacity, and impacting the overall organization as a system. Pre-tests and post-tests were taken using pencil and paper. The participant, mentor, and facilitator guides were provided in hard copy format, and were also available electronically as a PDF. Population and Sample Size Stage One: A typical phenomenological study has between 5-25 participants. The target population for stage one of this study was client-facing human service professionals who had been with the organization at least one year. Client-facing roles are roles that involve direct interaction or contact with the organizations clients. The total population that fits these criteria was approximately 575 employees. My goal for the sample size was at least 12 human service professionals. Participants were chosen using two strategies: convenience sampling and voluntary response sampling. Working with the human resources team, potential participants were notified via email of the study. They were asked to indicate their interest in an email response to me (see Appendix A). There was also an announcement of the study during a weekly management meeting (see Appendix B). At that time, participants were able to volunteer their interest. If there were more than 12 individuals were willing to take part, they would have been 48 enrolled in a second group, but that did not occur. All employees had to be in good standing with the organization, as noted by no employee performance issues for one year. Twelve participants attended the in-person focus group session. Three additional participants attended a private, oneon-one session held via Zoom. Pseudonyms were assigned to participants. Stage Two: The target population for this stage was new client-facing human service professionals. The goal for the sample size was at least 20 human service professionals. Convenience sampling was used. Being at the mercy of the hiring cadence of the organization, the participants were onboarded to the study in a cohort style. Each Monday brought a new cohort of participants until the minimum number of at least 20 was achieved. This took two weeks. The number of participants ended up being 24. These participants were assigned pseudonyms. Stage Three: The population for this stage was the individuals enrolled in stage two who were still employed at the organization at the time of the post-test and ensuing qualitative data collection focus group/feedback session. There were 20 participants still enrolled in the program at the time of stage three data collection; however, only 14 completed the post-test and attended the final focus group evaluation session. A second focus group was added to explore the mentors experiences and gain their feedback. This invitation was extended to the 21 mentors enrolled in the program. Ten attended the focus group session. In addition to the participants, the mentors also were assigned pseudonyms. Timing As a three-phase intervention, the intervention took place over the period of several months. Upon approval from the Institutional Review Board, stage one began with solicitation of 49 participants for the focus group. The participant invitation window was open for one week. After the invitation window closed, the 90-minute focus group was held. After the focus group concluded, follow-up interviews were conducted for two weeks. Data from the focus groups was analyzed and the intervention tools were created over a period of 45 days. Once the tools were created, stage two began with insertion of the intervention into the NEO program. I estimated it would take up to one-month get 20 participants rolled into cohorts for the Caring for the Caregiver program. It ended up taking two weeks. Once a participant entered the program, they spent 90 days in the active intervention. Once all participants completed their 90-day programming, they completed a final focus group. Limitations and Delimitations The population being studied brought with it several potential limitations. In the organization, client needs come first. If a client was experiencing a disruptive behavior and their assigned staff is taking part in the study, the staff needed to prioritize the client needs first. This meant that the participating staff may be unavailable to attend a session or may be late to a session. Late arrivals were permitted, but also disrupted conversation in the room. In a similar vein, I could not control the out of office time for participants, so if people were taking paid time off on a session day, they missed that session. A limitation that might have impacted my role as researcher is my position in the organization. I addressed this with bracketing. The biggest limitation that I foresaw was having to on-board participants in cohorts. This left the door open for participants to have different experiences. I worked to control this through a peer mentoring guide and facilitator notes. Finally, a limitation was the current turnover of new employees. Given that only about 50% of employees hit their 90-day employment mark, it was likely that 50 not all participants would still be employed by the organization by the conclusion of the research phase. In order to narrow the scope of the research, there were several delimitations in this study. The most notable delimitations were around the populations chosen as targets. The research participants had to be in client-facing roles, thus eliminating non-client-facing staff within the organization. I focused on client-facing roles because these are the roles that are more unpredictable, as they are based on client-engagement experiences, and these roles have the highest turnover. Further, during stage one, those invited to the focus group had to be employed by the organization for at least one year. This limited the voices of those who had been employed less than one year with the organization. While those employees would likely have had information to share, I opted to focus on staff more familiar with the system and with adequate, first-hand knowledge of operating in the developmental disabilities space. During stage two, the population was brand new employees, so the study left out all other employees in the organization. This choice reflected the organizations view that this was a pilot study. If there were productive elements to this experience, and the post-analysis deemed it worthy of peoples time, it would potentially be rolled out to the rest of the organization. A final delimitation was the research questions themselves. While there are many aspects of the system that would be interesting to study, and many lenses with which to view each aspect, I chose to narrow the scope and focus on building emotional capacity for client-facing staff. Rationale for Intervention The intervention in this study was informed by the literature review and my initial diagnostic research. What stood out to me during the review of the literature was that supply for human service professionals is not keeping up with the demand for those workers based on 51 increasing incidence of ID/DD diagnoses. Turnover with this population is significant. Unlike other industries, human service professionals hired into the organization must navigate a comprehensive pre-employment screening process because of the vulnerability of the population being served. They must submit to a drug screen and physical; a complete background history check (local and state law enforcement, driving history, sex offender, etc.); complete FBI finger printing; have three references; submit all formal education transcripts; take a TB test; have no felonies on their record; and have no previous interactions with the Department of Child Services. In short, those that make it through the pre-employment screening process have demonstrated considerable commitment to work for the organization. Having nearly half of those early-committed individuals abandon their roles within 90 days on the job suggested an area for adaptive investigation and progress. As stated in the literature review, employment has a significant impact on overall life enjoyment. People are drawn to roles that allow them to demonstrate their self-identified strengths, work in areas of interest, or align their personal values with perceived organizational values. Often, people are drawn to particular roles through the influence of a calling or other desire for meaningful work. Once in the desired role, job satisfaction is then often brought about through the enjoyment of meaningful work or being good at the work that is being conducted. Living a called life or being drawn to meaningful work has pros and cons and is often referred to as a double-edged sword. On the positive side, workers have the potential to have high job and life satisfaction. They are engaged in the culture, and they make great corporate citizens. A satisfied work life contributes to a more satisfied personal life. On the negative side, work as calling theory points to potential added stress and burnout due to overwork tendencies. One interesting indicator of job satisfaction is perceived fit, specifically how well the employee fits 52 into the work environment. If personal fit is not determined or there is a significant mismatch between person and environment, then the employee will begin the turnover intention process. Preferably before, but certainly in the early stages of the turnover intention process is the organizations opportunity to intervene. Research shows that intervention is possible through building emotional capacity, offering flexibility, and enhancing training supports so the employee can better withstand the demands of the job. During the initial diagnostic phase of the research, my informal discussions with human service professionals in the organization added color commentary to the literature. Most of the human service professionals I spoke with identified that their work was a calling or a chosen career path. Over 90% of the employees described the work as important or meaningful, saying that they either liked or loved the work they were doing because of how important it was to the community and to themselves. Most of the individuals listed their team as critical to their success and enjoyed their connection with the clients. They saw the work as challenging, but also felt a larger reward in helping others. On bad days, the sources that pulled them back to the organization were the clients and the team. Additional diagnostic work included informal conversations with longer-tenured human service professionals who had been at the organization longer than one year. What emerged from those conversations were four unique paths to the retention-decision process: peer support, supervisor belief that they could do the job, feeling special/called/otherwise better, and a sense that no one else could or would step up for the clients if they were to vacate their roles. The last path could be experienced as either very meaningful or very draining, creating a callousness or resentful feelings leading to burnout. 53 Table 1: Summary of Intervention Steps & Timeline Intervention Timeline Stage One: Participant Recruitment May 2023 Stage One: Focus Group May 2023 Stage One: Follow-Up Interviews May 2023 Stage One: Caring for the Caregiver Program Development June 2023 Stage Two: Caring for the Caregiver Program Training July 2023 Stage Two: Peer Mentoring & One-on-One Mentoring Sessions Stage Three: Final Focus Groups & Follow-up Interviews July October 2023 October 2023 54 Evaluation of Intervention As a phenomenological study, my focus was on the essence of the lived experience during the research phase. Similar to how the group helped shape the content of the intervention tool, the group who received the intervention also evaluated the experience. During stage three, participants from stage two gathered for a focus group session. There was one focus group for participants and a second focus group for mentors. These focus groups were held in-person as previously described. The focus groups lasted 90 minutes (See Appendix G). During the focus groups, there was open discussion about the intervention tool and how employees experienced the intervention overall. Data Collection Data was collected during multiple stages, and was triangulated between focus groups, individual follow-up interviews, peer mentoring recordings, pre-tests, post-tests, a feedback loop with mentors, and organization documents, such as turnover reports and historical data. During stage one, data was collected as volunteers participated in the focus group and ensuing follow-up interviews. During stage two, data was collected in the form of participant pre-tests, as well as recordings of training, and peer mentoring sessions. During stage three, data was again collected in the form of post-test data, audio recordings of the focus groups, and a follow-up interview with the facilitators. The follow-up interview was semi-structured. Focus groups were held inperson. The follow-up interview was held virtually via Zoom. All participants in the study were employees of the organization. Consent forms (See Appendices C, D, E, and H) were provided to all participants, and were signed and collected prior to their participation in each stage of the study. 55 Qualitative Data Analysis All data recordings, transcription, and analysis were supported using the NVIVO software. This software was designed to support analysis and coding in qualitative research. It helps the researcher to search for themes and analyze relationships between people, concepts, and processes. Inductive coding allowed the themes to arise from the qualitative data collected. Coding was implemented with the support of NVIVO software. All data stored in the NVIVO software was encrypted while in storage and in transit, ensuring that it was secure. NVIVO is also HIPPA compliant, so any discussion of client-related issues was protected. Quantitative Data Analysis While this was a phenomenological qualitative study, some quantitative data was useful in assessing the intervention tool, as well as to support data triangulation. The quantitative data for this study were the pre-tests and post-tests (see Appendix J and K), which are the Work and Meaning Inventory (WAMI) and the Perceived Person-Environment Fit Scale (PPEFS). Developed by Steger et al. (2012), the WAMI can be used in research and educational capacities without restriction. Permission to use the Perceived Person-Environment Fit Scale (PPEFS) was obtained from John Wiley and Sons Publishing. Both surveys are multi-point Likert-type scales. Results from the pre-tests and post-tests were entered into the open-source statistics program JASP to test whether there was a positive correlation between the implementation of the intervention and test scores for the participants. Confidentiality Besides following all protocols of the Institutional Review Board, I received permission from the organization to conduct research with the employees. Participants had any personally identifying information removed prior to publication and pseudonyms were used. Where any 56 personally identifying information may have been shared, permission was requested/granted in advance. Participants were able to choose if they preferred to take part in any personal, semistructured interviews following the focus groups. Participation during stage one was voluntary. Participants during stage two and three were auto enrolled; however, they could opt out of the research if they so chose. Participants in the study were asked to respect the confidentiality of other participants, and not disclose information shared during focus groups or peer mentoring sessions to employees outside of the study. 57 Chapter 4: Study Results The intervention for this study was developed using the foundational first principles of human centered design, most notably, profound respect for people. Norman (2019) summarized the four principles as: 1) ensuring that the core/root issues of the problem are solved, not just the problem as presented; 2) focusing on respect for people; 3) taking a systems viewpoint; and 4) testing and refining continually to ensure the needs of the people, for whom the intervention was intended, are met. During stage one, this manifested in an outlook that the people doing the work in the organization know the work best. In stage two, this principle was honored using a combination of self-determination (individual working on topics with a mentor) and codetermination (peer mentoring). In stage three the participants and mentors described the mutual flourishing experience that occurred during the intervention. With human-centered design as the approach, the wondering was if this intervention could allow for building of individual and collective capacities to create meaningful results. Stage One: Experiences and Content Co-Creation The target population for stage one was human service professionals who had been employed at the organization for at least one year. The individuals who attended the focus group session responded to an organization-wide invitation to the 575 people who fit the criteria. Twelve participants attended the focus group session, while an additional three participants asked to have one-on-one interviews due to their schedule availability. The focus group was held at an off-site location, while the one-on-one interviews were held virtually via Zoom. All sessions were recorded and later transcribed and coded using the NVIVO software platform. 58 Following the guidance of Monaro et al. (2022), data analysis began with reading and screening the transcripts of the stage one focus group and interviews. Data was coded for volume first, then patterns emerged into themes. Having worked in the environment for at least one year, the stage one participants shared personal recall of lived experiences, such that the experiences could help inform the development of materials for the Caring for the Caregiver program implemented during stage two. These participants helped answer the research question: How do human service professionals experience working in the ID/DD environment? Table 2: Stage One Codes and Narrative Themes Code Theme/Essence of Phenomenon Code Frequency Environment Emotional Support During Disorienting Experiences 19 Supervisor Emotional Support During Disorienting Experiences 13 Team Emotional Support During Disorienting Experiences 11 Communication Emotional Support During Disorienting Experiences 9 Clients Mission Alignment with Personal Values 14 Difference Making Mission Alignment with Personal Values 6 Training/On-Boarding Learning & Living the Work 11 Job Crafting Learning & Living the Work 9 Stress & Fear The Costs of Doing the Work 9 Veteran Advice The Costs of Doing the Work 7 Salary The Costs of Doing the Work 6 Theme One: The Need for Emotional Support During Disorienting Experiences One consistent theme throughout the stage one data was the need for emotional support during disorienting experiences. The location where the participants worked within the 59 organization appeared to impact whether they felt supported by the environment with a functional team, an engaged supervisor, and appropriate communication. Emotional Support During Disorienting Experiences: The Environment As the focus group began, and participants began sharing experiences relating to the organizations culture, their stories nested into two divergent camps either participants expressed feelings of gratitude for being emotionally supported or participants expressed feelings of depletion from having to self-support in the system. Laura described her experience, I was hired as a director of a very intense program and I'm not going to lie, it almost broke me. And I'll probably get emotional, but I was burned out. I was considering leaving the field. There was a traumatic incident, a closure of the program, and a kid died. I was taken care of during that process. The relationship with [authorizing body] at the time was very poor, it was a very toxic environment at the time. And I was supported. And I mean, I'm so loyal to [the organization] for that because I could have been kicked out, fired. It was a bad scene for [the organization]. And they were able to look at the whole situation and not point their fingers. Knowing the situation that Laura was describing, Brad added, I can sympathize with that because I had that kid in my classroom. And kind of seeing everyone come together after thatthat was huge. That was very, very difficult. Laura thanked Brad for his affirmation of her experience and added, Its okay to say this is a hard job. We dont always feel like it is okay to say that in every context. In further speaking to the emotionally supportive culture, Natalie shared, The environment is a little crazy. You never know what's going to happen. I really like that in my position I have supervisors that check in with me every week. I kind of make 60 my own schedule and see who I want to see when I want to see them, so I really like that. Kayla echoed Natalies comments, I have the confidence that I can actually do this job. I have found my voice. Mandy spoke to her experience of coming out of a hard season personally and relying on her coworkers to support her, Im just getting back to my best self againactually being able to check in and feel supported in that way. [Lack of] Emotional Support During Disorienting Experiences: The Environment Conversely, some participants expressed a lack of support within the system. As participants shared their experiences, what emerged was a lack of an outlet to express the emotional toll the job takes on the participant, which among other things was chalked up to the sheer volume of crises. Kayla began by saying, I was really glad that the emotional support piece was brought up. I think that's really something that I've been struggling with lately you know, I might have this call with my supervisor who's great, but then we end up talking about like, Did you email me about that or did you send that? Did you submit that thing? Or, yeah, that's a really tricky situation. Here's what you should do about it. Its either administrative or it's more, like, just solution-based or, you know, kind of the nuts and bolts of the job. But there's not that like, Oh, gosh, this situation must be really hard for you because, you know, you're triggered by a lot of these things experience. Carol added her experience, I always feel that Im taking up somebody's time with this stuff. There's always, like, probably three or four crises at one time. So, I have to pick the one thing that is the most 61 pressing. There's also the stuff that is emergent, you know, that needs to be addressed immediately. Tashas experience of the organizational environment was described as one of resilience. She said, In my time, I think the people that stick around are resilient people. There is the employment piece, but we're also keeping all this stuff for other people, right? Other people's stuff that then brings up our own stuff and not having an outlet for that. It is very interesting for the organization to not recognize it. Speaking further to emotional resilience, Mateo added, I think sometimes that people come here with a different notion of how they have to deal with people, and they're not cut out for it. So, a lot of people, you know, say if they last one week, it's a miracle. Some of these peopleI can look at you and, like, you're not going to make it. I also think some people don't feel like anybody has their back. Emotional Support During Disorienting Experiences: Supervisor Participants included their supervisor relationship in their assessment of whether or not the culture was a supportive one. What made one supervisor good depended on the participant. One expression of having good support came in the form of autonomy and encouragement to try new things. Brad began by sharing about his supervisor, stating, I feel like she does a really good job of making us feel important and giving us the freedom to do the things that we want to do. Kayla agreed, saying of her supervisor, I have a sense of really hitting the jackpot with leadership I feel like I've had the support, especially in the last couple of years, to really try new things. Stephanie added, 62 My management, I think, is really great. I really like that they trust us to do the work, and if we have questions, just come to them. I never feel like I'm micromanaged, which was an issue with my old job I didn't like. Another aspect of a supportive supervisor emerged as one who was available. Tasha shared, It's hard to think of a situation where I felt like I needed help and wasn't given it. Mandy added that she frequently texts her supervisor for support. I can text her if I'm anxious about something. I got an email that my billing was messed up the first month, and I called her really anxious, and she calmed me down. So, she's really great. I text her like ten times a day and she's great. [Lack of] Emotional Support During Disorienting Experiences: Supervisor Examples of lack of support from supervisors were not as extensive. However, two people spoke about experiences for them that were very powerful and led to significant feelings of not being supported. Tasha shared an experience early on at the organization where she felt she was not heard by her supervisor. She said, I was very vulnerable and had just shared how I was treated by people that I'm supposed to look to for support and to advocate for me. In sharing, I was very vulnerable. After sharing the information, I just got a thank you and kind of was ghosted. No follow up. No communication. You know, I didnt really feel valued. Natalie shared a different experience where she needed support. She described the pressure of being put in a clinical on-call position and not knowing how being on-call even worked. She said, 63 At that point, we were getting calls from the whole campus. I just wish maybe that my supervisor could have met with me, like maybe the week before I was on call. I was really flustered, and I feel like it could have been set up better. Emotional Support During Disorienting Experiences: Team The experience of being a part of a supportive team was one that nearly every participant spoke about. While each work team had a distinct set of norms, the unifying bonds between coworkers and the willingness to jump in to offer support stood out. James shared, I feel like when I got here and after my first few years, I can honestly say, like, I could never see myself doing this for another setting because of the types of relationships that you can build here with your co-workers. I think it's a pretty unique experience. Susan agreed, I love the co-worker relationships that I've made over the years. It's my team and my coworkers and families and my clients, which most of my clients I have had most of my ten years. And I think that's a special thing. Conner spoke about how his team often covers for one another. He said, There's a lot of closeness amongst everybody on my team. The team that we have is why we can easily say to one another, Hey, I've got a meeting, you've got me on my class? And it's no hesitations. No, question. What do you need me to do? It's a jump right in mentality. Jane referred to her team as a sisterhood, stating, It's great to sisterhood. It's support for you, no matter what. We care about each other so much. Weve worked together forever. We work together so well. So that's been really, really awesome. 64 Mandy shared that she appreciated being able to be herself, while appreciating how others show up in the workplace. She said, We hold each other to a very high standard as far as professionalism and the science of the work, but then also can be laid back can joke. So, I think it's just being able to be myself, but also, we all have the same passion for the science of helping the kids. So, everyone aligns, but everyone's so different that it makes it fun, too. Stephanie ended by saying, Were just all in this together. Emotional Support During Disorienting Experiences: Communication As good as many participants felt their team was, they expressed challenges with working inside a large, complex organization. As the participants diagnosed why they thought there were breakdowns in the system, communications seemed to be an area for additional work. Catherine explained how her team achieves effective communications by noting, We have meetings almost every month where people can voice their opinions or where we are in the know of changes that are going onlike who's in charge of what and when, why we're doing things. So, when you feel informed and when you feel like you have a voice, you feel like you're wanted and you're part of a team and you're in the know. So, when I hear stories from other lines of our work, I feel like thats the missing factor. Carol shared her goal for more open communication on her team by saying, I'm very open with my communication and how I want things to be or how they should be. I think definitely just some more open communication, when it's allowed to happen, I feel like could be beneficial moving forward. 65 [Lack of] Emotional Support During Disorienting Experiences: Communication Matteo shared his frustration in trying to stay connected to the organization by stating, Its a disconnect between management and people taking care of the kids that have no idea whats going on. Jane wondered if it was due, in part, to the size of the organization by positing, I know we do great things as a whole, but it is sometimes hard to feel connected because it is a big organization. Catherine echoed the need for better communication by noting, I feel like if there was just more communication from top to bottom and bottom to the top it would go a long way. Mandy spoke about the need to communicate but being mindful not to overcommunicate due to client HIPPA issues. She said, I think in the past, I felt like people have wanted a little bit more open communication. Not necessarily being transparent because a lot of times that's not an option. So, what I think our manager is really good at is also communicating what's the root of the issue here and if we can try and figure out how to set you up for success. Theme Two: Mission alignment with personal values system Another theme that emerged was the satisfaction felt by participants as they discovered the organizations mission of serving clients aligned with their personal values. It started with sharing feelings of appreciation and love for the clients served in the milieu. Love for clients Brad shared how his clients are his number one reason for loving his work by saying, I can't even begin to name one of the things I love about [the organization]. There's just so many. I guess, the clients, of course. They keep me living in the moment all the time, you know. So, that's probably the number one thing. 66 Conner continued, I just love working with my teens. I feel like I've been lucky to work closely with people. And we're just all in it together. And I love that. Stephanie spoke about how she worries about what will happen to her clients when she retires. She said, Especially with my three guys, I worry, you know, very much about it. We can't keep people for over six months in our house. They're fabulous guys. But you know, they're a lot. And like nobody, nobody wants to stay. Kayla added that she enjoys being a part of her clients journey toward success, saying, I most enjoy the relationships that I have built with not only staff, but with the kids. To see when they are successful and kind of being a small part of their journey. Tasha spoke of how even though the clients have disabilities, they are well aware of how they are perceived. She said, All of these kids are way more aware of things than anyone gives them credit for. Whether that's body language, how someone's talking to them, how someone's reacting to them. At the end of the day, they can teach us as much as we can teach them. A lot of times they can teach us how to how to teach them. And then everyone is successful. Making a Difference In addition to commitment to and affection for the clients, participants spoke about meaningful work, in particular making meaning out of the work that they do. A common phrase that bubbled up was difference maker. Stephanie shared, I love doing small things with great care. They make a difference in the lives of the people I work with. She continued, I can front load them for a really good day. Im third shift and by the time the first shift comes in, we are ready for a good day. And it feels great. It feels good to give that to them and they love it. They give so much back to me, and I just love it. I can be the 67 architect of their day. Now it'll change and I can't change anything later when I'm sleeping, but we started out really strong and really good and there's power in that. Matteo added, I just really like making a difference in peoples lives. Natalie shared a similar sentiment, I am just hopeful that I could make a difference, that what I was doing mattered, that somebody's life would be better because I was there to be a part of that. Kayla concluded that being recognized for the difference she was making was challenging to accept at first, until she got used to praise from a supervisor. She said, Having somebody constantly tell me I'm doing a great jobthat was hard to adjust to. Actually, being complimented all the time for what I was doing and realizing that I was making a difference. And that really helps in just knowing that you're making a difference. Theme Three: Learning and Living in the Work The process of figuring out the work was something that participants discussed at length. While all participants attended a mandatory, two-week orientation, the specifics of their roles were not shared until they graduated orientation and could begin engaging with clients. This is due to a variety of confidentiality and security requirements from authorizing bodies. So, once out of orientation and transitioned to on-the-job training, experiences ran the gamut. Learning the Role Mandy started by saying, It took me a while to get settled in just because this job is verythere's a lot of components to it. So, not only what the job was, but understanding everybody else's roles on the team and where I fit in and trying to balance thatI'd say it took me a good six months to realize what the heck I was doing. 68 Tasha felt alone once she was released from orientation. She said, A lot of the job I had to learn on my own. And a lot of times I would make a mistake. Tasha added the lack of on-the-job training support for her was experienced as not knowing who to turn to when things came up. She said, It took me about six months to really just figure out my job and figure out who to go to or where I need to go. Kayla shared a similar feeling, I feel like I definitely could have used a little more guidance at the very beginning, she said. Natalie added, I was forced to figure it out myself. I remember the first time I was on call; our electronic health records system wasnt working. I was so stressed out, like I was having a freak out getting calls every five minutes. I don't feel like I was really prepared to do that. I just don't feel like things were explained to me as much in depth as they could have been. Job Crafting While it may have taken some participants time to get their feet underneath them, once they did participants found that there were opportunities to shape their roles towards their strengths. Laura saw this opportunity through a lens of appreciation, stating, I appreciate the flexibility and that I dont feel micromanaged. That is a tremendous reason why I stay. Kate had a similar sense of appreciation, sharing, To really just kind of come up with new ideas and be met with like, well, why not try it? That has been really refreshing and I think that that has really made me kind of feel more invested on an individual level in the agency and feel more valued. Susan saw the ability to craft her role as an outgrowth of the industry itself. She stated, My whole career is trial and error. So, I think for me, there were times where I kind of just had to figure out things on my own as far as the implementation of a protocol or pairing with a client. 69 Kayla appreciated that as her skills grew, so could her role. She said, I feel like I kind of just grew out of the role and wanted something more clinical. And it's just been a really good change for me. Natalie shared a similar story of how her current job came to be. She described, They actually created a job because I was doing it. I was kind of, like, onboarding all our new people because I wanted to be there to help. When I started, I didn't have anybody to help me. I felt so confused, and so when somebody new was coming in, I could recognize that and I kind of just made it a point to be a point person. So, I thought that was pretty cool that they created that job because I was already doing it. Mandy spoke of her awareness of the burnout potential in her own life and how she uses job crafting to combat that potential, stating, I dont want to be a burnout statistic. We have the awesome ability to be able to create new things and be different and do different things. I'm excited to see what that looks like moving forward. Theme Four: The Cost of Doing the Work Harry Browne is quoted as saying, Everything you want in life has a price connected to it. There's a price to pay if you want to make things better, a price to pay just for leaving things as they are, a price for everything, (Browne, 1973, p. 140). The essence of this quote is lived out in the human service professionals who participated in stage one of this research. The cost of doing this work is quite high at times. Among other things, there is the physical toll it takes on the body, the emotional toll it takes on the heart, and the financial toll it takes on the family whose loved one chooses to work in a low wage industry. Feelings of Stress and Fear The first emotion that came up during the discussion was one of confusion and shock. Participants recalled that when they were new, they had little understanding of the work and did 70 not understand the treatment/therapeutic processes for those with ID/DD diagnoses. There was also shock and confusion with how the disability manifested in many of the clients served by the organization. Tasha began, The first time I went on a unit, I'd never seen anything like that before. Just different. And, like, thinking about the kids actually living there and kind of going down that sadness rabbit hole. Like, this is so sad. I had a little kid show me his room and I'm like, Oh, you live in here. This is where you live. You should be home with your parents, you know, tucked in at night. So, I guess it was just a culture shock. I'd never experienced children's residential. So, that's part of what the shock was. The kids behaviorsit takes a bit to get used to. Natalie echoed Tashas experience, I was shocked, but I was hopeful because I knew I could help. So, initially it was confusion, then shock, then hope. For participants currently experiencing stress in their role, the toll was significant. Jane sighed, I would say in the area I work on; the stress level has increased significantly. I feel for the last year theres just been no let up. It's too stressfulthe stress on stress, which was leading to not a lot of fun. Matteo described his work by saying, You know, you're out there, you try your best. And what you do could go wrong in the wrong way. You know that. So, people get afraid to do something. With time, some have learned to manage the stress. Laura shared, I think it's the amount of stress that this job can bring, and somehow, I can't quite put my finger on it. I think it's probably because of my team and the people that I work withI 71 do manage to not carry that stress home. However, there were times where that was not the case. But I feel that now and I think that is a beautiful thing. Mandy concluded, It's definitely emotionally, physically, mentally taxing. So, I tell everyone new hires, family, friends, that my career is a very high risk, high reward. Financial Constraints It bears noting that participants raised issues with their wages. While they recognized that they did not choose to work in a high-pay industry, they also felt modest increases in salaries due to covering for unfilled positions made sense. Kayla spoke about how, for her, salary can get tied up in self-worth, stating, I've been working hard to not make my self-worth about what the salary is and being able to keep advancing. I know that has nothing to do with how good of a therapist I am. She continued, The main thing that bugs me is that I started eight years ago and now the starting salary for this role is what I'm making now after eight years. I look around all the time, but I don't want to go anywhere else. Mandy added, There was a time where I knew every other clinic paid more than what I was making here. In my first year, we actually got three raises to become a little bit more competitive, and that's amazing. Solutions from Within: Veteran Advice The participants were made aware that they were providing input for new employees, so they spent time brainstorming ways to improve the new employees experience. The list of suggestions for the improvement of the organization included: Creating a more extensive crisis management/training program, which includes somewhere people can go to talk after the crisis is over. Encouraging staff at all levels of the organization to participate in group experiences, outings, activities, and supporting clients. 72 Creating a peer support network for when a crisis happens, so it would not feel so isolating. Focusing on self-help and wellness perks. Offering more paid time off earlier to prevent overworking and allowing for self-care. Creating a space where people can go to process the heavy stuff the job brings. After considering how the organization might improve, participants also provided guidance for new employees coming into the organization. Their tips included: Be honest with how you are feeling and dont get to the point where you just blow up. Make sure you are not taking on too much overtime right away. Stay focused on what you can control. Be present and dont let drama consume your life. Dont hesitate to speak up if youre not feeling okay. Youre not alone. 73 Stage Two: The Intervention As a result of the literature review and analysis of the shared experiences of participants during stage one, the content for the Caring for the Caregiver program was developed. Once content was created for the program, the two intervention facilitators reviewed and edited the content of a training session to be held during New Employee Orientation (NEO) and six peer mentoring sessions. The areas of focus centered on introduction of a mindfulness practice; building a self-care practice; orienting to the new environment; understanding personal agency and practicing emotional resilience-building skills; right-sizing wins and losses; and providing a conduit for questions and concerns. Stage two began as the intervention was applied to new human service employees entering the system through NEO. The goal for the sample size was at least 20 participants. During the first NEO session that began on July 10, 2023, 15 of 18 possible participants voluntarily enrolled. Three abstained. During the second NEO session that began on July 17, 2023, nine out of nine possible participants voluntarily enrolled. The total number of participants was 24. In addition to the participants for whom the intervention was applied, there was another group of participants who shared the experience of the Caring for the Caregiver program. This group was the mentors assigned to the participants. There were 21 mentors who volunteered to participate in the Caring for the Caregiver program. These mentors received training on how to be a mentor, were provided a mentoring handbook, and then were assigned a participant. The mentors provided feedback via a feedback loop after their one-on-one time with the participants every other week. Mentors also reminded participants when peer mentoring group sessions were being held to encourage optimal attendance. 74 Table 3: Mentor and Participant Pairing PARTICIPANT PSEUDONYM ASSIGNED MENTOR PSEUDONYM Aidan Jane Zola Kayla, then Cara Nala Solomon Kofi Eric Amara Chrissy Ola Cara Imani Daniel Kamari Hope Bri Beth Emily Mike Charlotte Nikki Ada Melissa Elias Cameron Mackenzie Sarah Taylor Mary Maya Lindsey Grace Hope Jack Solomon Nicola Drake Stella Tom Femi Sandy 75 Casey Sandy Brooke Jillian Jabari Adam NEO Training Two training sessions (one for each cohort) were held for Caring for the Caregiver program participants. Co-facilitators, Kim and Sarah led the sessions. During this training, the program was introduced, as were the key concepts that would be covered during the 90-day program (Appendix N). Prior to commencing training, participants signed consent forms (Appendix D) and took their pre-tests (Appendix J and K). Facilitators used an analogy of an oxygen mask as an entry point into the content. On an airplane, passengers are told that in case of emergency, they should put their own oxygen mask on first before turning to help others. This program would be akin to putting on an oxygen mask. With that as the setup, facilitators then took participants through a grounding/mindfulness exercise to help them get into the room mentally. After the grounding exercise, Sarah asked participants, How are we doing? What is coming up? Casey shared, Im excited to finish orientation. Grace followed, sharing her nervousness about the mandatory exam coming up. In response to this, Sarah said, I think were all ready and excited for you all to be successful in orientation and then get to the next phase. And we will be here for you. The group moved into talking about the Circle of Control concept that would be brought up consistently over the next 90 days. Popularized by Stephen Covey (2013), this concept explores three concentric circles: the circle of control, the circle of influence, and the circle of concern. For the purposes of this program, facilitators chose to focus on the circle of control 76 (things that people can control) and things outside of the circle of control (things that people cannot control). They also encouraged participants to consider what was within and outside of the circle of influence as they were learning the organization and their roles. Figure 2: Circles of Control After the Circle of Control discussion, the concept of burnout was addressed. Kim asked people if they could name what burnout felt like. Participants answered in rapid fire. Thoughts included: Overwhelming Exhausting Tired mentally and physically 77 Overstimulating Withdrawing Frustrated and angry about a lot of things at once After addressing what burnout felt like, the group was presented with opportunities to begin building their toolkit, which included addressing self-care and burnout prevention, as well as resilience-building tools. Once the groundwork was laid, mentors were invited into the room for conversation and a meet and greet with their participants. After the meet and greet, facilitators reminded participants to focus on self-care (something that can be controlled) and the calendar for the coming weeks. Training was concluded and the group was dismissed. Peer Mentoring Sessions Upon graduation from NEO, the participants entered the mentoring portion of the Caring for the Caregiver program. This program offered six, bi-monthly, one-hour peer mentoring sessions, as well as bi-monthly, one-on-one mentoring sessions. In essence, this meant the participants had weekly touchpoints from the program. Participation was strongly encouraged but was not mandatory. This was because the participants worked all different shifts (1st, 2nd, 3rd), as well as weekends and their peer mentoring time would be held consistently at 2:00 pm on Thursdays. This day and time were selected because it was the time during the week when there were the most staff in ratio. As described previously, the sessions were audio recorded. During the last session, participants took their post-tests. The content for the six peer mentoring sessions included: Week One: Building trust, self-care, supervisor relationships, and orienting to the culture. Week Two: Meaning making and team building. 78 Week Three: Personal agency building and resilience. Week Four: Cultivating experiences and demystifying what a good employee is. Week Five: Finding the little wins and quantifying the losses. Week Six: Transparency and accountability. Themes that emerged from conversations during peer mentoring were similar to those discussed during stage one. An exception to this was the emergence of a new theme around how the client-participant relationships were formed. Table 4: Stage Two Codes and Narrative Themes Code Theme/Essence of Phenomenon Code Frequency Supervisor Emotional Support During Disorienting Experiences 5 Team Emotional Support During Disorienting Experiences 5 Environment Emotional Support During Disorienting Experiences 5 Resilience Emotional Support During Disorienting Experiences 3 Difference Making Mission Alignment with Personal Values 5 Values Mission Alignment with Personal Values 3 Experimenting Learning & Living in the Work 7 Frustrations Learning & Living in the Work 5 Observations Client-Focused Care 5 Relationship Building Client-Focused Care 4 Comfort Client-Focused Care 3 Theme One: The Need for Emotional Support During Disorienting Experiences Similar to stage one, a consistent theme throughout the stage two data was the need for emotional support during disorienting experiences. Again, much like participants in stage one, 79 the location where the participants worked within the organization appeared to impact whether they felt supported by the environment with a functional team, an engaged supervisor, and an environment within which they could sustain themselves and build their emotional resilience. Emotional Support During Disorienting Experiences: Supervisor As participants were acclimating to the system, they noted connections with supervisors and their mentors. Kamari shared, Kudos to my mentor. She is giving me confidence that I can always come to her. It feels good deep down to know my manager is a good leader. Nala also noted the positive relationship with her supervisor by stating, Our unit is very challenging. We talked to our manager, and she is so kind. We talk to her about everything. She says, You can do it. You can do it! However, not everyone felt supported by their manager. Bri described her experience, My manager just threw me out there! So, I picked someone [to shadow]. So, I chose T.J. I chose him because he seemed like he knew what he was doing. I was just like, Can you show me how to do a search? And so, I guess we just started practicing together. I believe he taught me the right way. Emotional Support During Disorienting Experiences: Team Another source of emotional support for the participants was the team. Charlotte described how her team made her feel by saying, I love my team now. Theyre so supportive and encouraging. It is very easy on the mind knowing you have all these people to turn to. Jack felt similarly, The team and I got along quickly. My team is constantly asking if I am okay. It is a mix of good energy and expectations because things can go south very quickly. But Im never 80 alone. There is a mutual understanding that we all need to be there for each other. Ive never had that in a team before. A couple of weeks later, Jack described an emotionally charged scene with the clients in his unit. He described it as his most stressful day, but also a day that he, generally felt supported amongst the chaos. He noted, I think theres more trust with my fellow workers and me now. Amara saw her mentor as a part of her extended team. She said, Ive gotten a lot of support from my mentor. She was there from day one, checking in, calling, texting and making sure I am okay. She did an excellent job of checking in with me. Emotional Support During Disorienting Experiences: Environment In navigating the challenging environment as a system, participants held mixed reviews. Emily stated, Its been great. Its awesome. Its overwhelming just trying to learn the system and all the people that I need to know and communicate with. Not every participant felt as positive about their situation. Amara shared, When I was first on my unit, they told me I wouldnt make it, but its been a month. Jack noted similarly, I feel kind of helpless where Im basically a glorified punching bagits so stressful because every single thing you do will be remembered. So, it feels tiring. Emotional Support During Disorienting Experiences: Resiliency From the first peer mentoring session, participants shared doubts about whether or not they could make it in the system. Bri said, I keep asking myself, How do they do it? I was crying yesterday. They said soon I will be used to it. Later, Bri noted that her new role had been challenging her emotionally. She said, Its definitely been a struggle for me, but Im here. I have no choice but to keep pushing. So, thats what Im trying to do keep pushing to get to where I need to be. Or not even 81 where I need to be, but where I want to be. So, it has been a struggle. They say to leave your problems at the door or whatever. Sometimes I can do that. While not doubting that she could do the work, Maya also wondered how to build her resilience for the emotional rigors of her role. She stated, Im very fortunate. I have a great team and Im learning from what they do, which is fantastic. Ive done this for many years, but its the first time that Im engaged with clients of this severe level of trauma. And I meantheres a lot of them. I have a client that was divulging all of these truths of her life. I was ready for it, but I didnt know what to say. I am not prepared to be a therapist, but I am fulfilling that role in that moment. I dont want to cross a line or boundary. What happens when someone tells you they were molested for 12 years? What do you do next? How do you respond? I thought I was prepared and quickly learned that I was not. As the program was winding down, Elias shared how he had progressed by saying, Im accepting a lot of things. Im definitely not trying to hide the stress or anything like that, but we just have to work things out on this one day. Its been chaos the past two days and Im just kind of coasting now. Its a nice feeling. Ola recognized that she needed more time to build her emotional resilience. She shared, I dont think I will continue. Its a ticking time bomb. Sometimes when I go home from work, I cant sleep. I stay up until two, three, or four in the morning reminiscing on every scene as if Im trying to figure out what I did wrong, what I did right. Im not sleeping, so when I come back the next day, I have a headache. Jack agreed by saying, You knowits just trying to balance it all and stay motivated to keep to that why for why we are here. 82 Theme Two: Mission Alignment with Personal Values Difference Making Based on the reflections in stage one, as part of the program, participants were encouraged to consider where they might be able to enter the treatment program of the clients by making a small, positive difference in their clients lives. This was explored over time. First, by recognizing when others seemed to be making a positive difference. Participants articulated these experiences to the peer group. Ola said, I heard someone say to just sit with them. One staff plays cards. He gets them laughing to get them familiar with him. I heard that makes clients less likely to act out when theyre engaged with staff. Later, participants began to describe how they felt they were making a difference. Nala described a situation on her unit, I had a client that was brought onto the unit. He was saying a lot of negative stuff about himself there. He wanted to hurt himself. I engaged him in a lengthy conversation, even though he wasnt listening at first. I said to him Your name is [NAME]. You are not your diagnosis. You are [NAME]. He was able to calm down and not hurt himself. It was beautiful. Having a conversationeven when it was hard. We were all scared because we didnt think he was going to back down. Maya described the impact she was making by sharing this story, Every week everybody gets new lessons. I always start with woos and poos. Woos are good things and poos are bad things. My office is adjacent to the kitchen, and I can hear it in there sometimes. I was typing and I could hear a kid in the kitchen having a conversation with his teacher about woos and poos from the night before. It was something very small, but I was glad it was translating and that they were using it as a 83 way to describe what was going on. Its kind of a segue into a bigger conversation. So, that was really cool. Values When some participants felt they were living the mission, they described feelings of satisfaction. Jack shared, The good times are great, you know? Those small ten-minute windows when someone is not having a behavior. It is great. He went on to describe how he sees his personal values lived out on the unit, One of my coworkers has a very nice sense of true respect towards the individual. So, hes able to quickly just know what they want. And a lot of the clients really just want to be respected. He knows the right way to calm mostly all of them just by being there, but not in their personal space. Maya described valuing flexibility, I like having the flexibility to adapt and change as need be throughout the day. Our curriculum is not set in stone. Like, this is what my day has to look like. If it breaks down our day is ruined. Instead, we can kind of let it flow and change what we need to to make the day go smoother. Theme Three: Learning and Living in the Work Experimenting Experimenting and co-creating experiences and opportunities was a reoccurring theme. Participants seemed to understand that the environment they were entering offered opportunities for job crafting and creativity. Jack summed up the experimental environment by saying, Its such a complicated ecosystem with our clients. One small thing happens to one client, and you 84 have to be careful that you dont set off a chain reaction for the next three hours. Nala spoke about how she looked for engagement opportunities, What Ive seen some staff doing that I like to do is introduce a game to the clients, aside from playing cards, coloring, or watching TV. We did four different kinds of games in one day. We had a race within the units. The clients were all jumping and laughing, and we had fun! Femi described experimenting in his workplace, The two guys I work with are nonverbal. They communicate with signs. One day I brought in a basketball because I am my sons basketball coach, and I spoke to them about basketball. They loved it. I am going to get my manager to buy us a basketball. Femi was not the only participant to share something they enjoyed with the clients. Stella shared, Last week was a little more on the crazy side because we couldnt find the TV remotes and it was the weekend and the clients were stuck inside. Twelve hours. No TV. No nothing. So, I went in the back room and found some paints and they painted. Frustrations Communicating feelings of overwhelm and being able to voice frustrations to the peer group was one way that participants used their peer mentoring time. Later in the program, Casey shared during group discussion how she was feeling. I only have two eyes! You have to keep your eyes on everything. From the second the kids wake up to the second they go to bed; we are always moving. Jack described a delicate client-family situation and how it impacted him emotionally. He said, Its kind of like rolling a boulder up hill. Its at a point where we cannot do anything, so it is very frustrating. 85 Theme Four: Client-Focused Care Observations Some participants used observation as a technique to build relationships and focus on client care. Femi commented on his first week with his clients, I discovered that they can do some stuff for themselves if you give them instructions. Nala also spoke to the need for observation, Training helps, but on the job, you have to study your clients. We go by observation. I can see the triggers from each of them. I see that this is what triggered this and so on. Amara agreed, One thing I observed is that these kids are really smart. They know that theyre doing. Relationship Building Kamari noted early on that he enjoyed the time with his clients by stating, I like being around my clients. I think I could work 16 hours easily. I typically dont like working over 12 hours, but I just love being around them. He added, Sometimes they really make you laugh, and the day goes by so fast! Casey wondered if part of the relationship building task was in allowing yourself to be tested. She described, I think a lot of it has to do with the relationship you have with the child. Because since we are new, they try to see how we are going to react to situations. But youre going to be friends with them. Youre going to be nice to them, so that they know they can be in a relationship with you. Nala spoke of how she enjoys the start of her shift, I love the start of a daythe peace and love on the unit in the morning when the clients wake up. Femi, who works with adult male clients, spoke of the joy his clients have when he works. He said, They love me coming around because 86 I happen to be the only guy that works there. So, whenever I am there, you know, it is pure love. Comfort/Discomfort Exploring the difference between expectations and reality was elevated as a factor in the comfort of participants. Maya shared, Im not exactly doing what I have done before, but that has been great. Ive loved the learning curve and working with the clients that are older than what Im used to or was previously used to. And Ive missed this age group, so Im glad to get back into it. It provides a sense of comfort and stability, like getting back into the routine of something that I have done. Amara applied this difference to the shifts, saying, I feel so blessed. Second shift is great, but I dont like working first shift. One-on-One Mentoring Sessions As the participants were sharing feedback and experiences in the peer mentoring group sessions, they were also assigned a mentor for one-on-one exploration. Much of the content in those sessions was confidential due to conversations about specific clients; however, the themes that bubbled up from the feedback loop aligned with what was occurring in the group experiences, particularly around the ideas of needing emotional support during disorienting experiences and learning and living in the work. Theme One: The Need for Emotional Support During Disorienting Experiences Mentor Mike shared, Emily has expressed some anxiety stepping into her new role. The support she has seen so far, though, seemed to ease her concerns. Mentor Jane shared a similar 87 assessment, My mentee was excited about how much support he feels like [the organization] will provide to him. He talked a lot about how important support is to him in this field. Aside from the jitters of a new role, there were disorienting experiences that negatively impacted participants. One mentor, Chrissy, spoke about an experience Amara had, Amara was pulled out of ratio last Thursday due to a client allegation. She was sent home and called me asking what she should do. I told her to just be patient and that they were following policy. Amara called again on Sunday, and I returned the call. We talked again Monday and Amara was cleared to return to work on Wednesday. I feel Amara handled the situation well but was worried and had lots of questions. She is a positive force and a good staff. I told her she will make it. Ola spoke to her mentor, Cara, about feelings of struggle. Cara described, She seemed very worked up and defeated. She stated that its getting harder to redirect the clients. We talked about making sure to interact with them when they are doing something good like coloring or playing card games to build that relationship with them. Theme Two: Learning and Living in the Work Mentor Marys conversation with Participant Taylor centered on the clients. She said, We discussed what population she wanted to work with, and I gave her a rundown of what to expect. Mentor Nikki shared that Participant Charlotte was also focused on client relationships in her work, stating, For some of her clients, Charlotte is trying to figure out how to build a good rapport with them when she wont see them that often. Participant Jack also had a conversation with his mentor about building rapport. His mentor reported, 88 Jack asked me how to build assertiveness skills. He also asked about when is it okay to redirect the clients. I was able to give him some guidance, but I am going to circle back with his manager to ensure we support him. Mentor Hope helped Participant Grace after a client issue occurred. She described, Grace and I met on the unit to discuss how she was doing after an incident of physical aggression. She was nervous, but then was able to express she needed more tools in her belt. She and I covered more skills in regard to using proactive steps with the clients. Stage Three: Intervention Evaluation Upon completion of stage two, participants were invited to return to one of the two focus groups to evaluate the program. The first focus group was for the participants to whom the intervention was applied, and the second focus group was for the mentors. A third and final analysis was conducted via Zoom with the co-facilitators to capture their feedback on the overall experience. Participant Evaluation Thirteen participants attended the focus group analysis session. They met for 90 minutes to discuss the experience of working in the ID/DD environment, as well as ways the Caring for the Caregiver program influenced elements of retention. Further, they offered an analysis of the program. The themes that emerged included the continuing need for emotional support during disorienting experiences, how caregivers valued the clients, the emotional cost-benefit analysis of working within the organization, and a program analysis. 89 Table 5: Stage Three Participant Codes & Narrative Themes Code Theme/Essence of Phenomenon Code Frequency Individual Needs Emotional Support During Disorienting Experiences 8 Check-in Opportunity Program Analysis 6 Mentor Program Analysis 3 Client Relationship Caregivers Value for Clients 6 Benefits Cost-Benefit Analysis 5 Costs Cost-Benefit Analysis 4 Theme One: Need for Emotional Support During Disorienting Experiences Participants assigned positive feelings to having a program or person that they could turn to for support. Nala described the assurance she felt with her mentor by saying, Having somebody that is going to listen to you, feel you, and try to work with you and your own feelings. They show understanding, compassion, are empathetic, and are willing to provide results. That is the number one thing I am attracted to in working with [the organization]. Ola recognized that while the job can be stressful, having someone check in on her was an important part of the experience. She said, It was not great the last time I was working, but I appreciate working with [the organization]. And my mentor always asks me, Are you ok? That is really good. Always when I see her it puts a smile on my face. She asks me, Are you doing okay? Is it going well? So, it makes me feel good. 90 Emily added, I have enjoyed it. I think that the people are very nice and always willing to help if something's happening or if you need anything. Jack followed that up with appreciation for being given a dose of reality mixed with humanity. He said, Even with all the challenges that kind of revolve around the unit and working more, as everybody was saying, this is the first job I've had where communication actually does kind of matterI've never gotten a sugarcoating and I really appreciate that because if you tell it to me straight and just say, that this is how it's going to be, I understand and will not be as stressed. Theme Two: Program analysis for individual impact In their analysis of the program, what emerged was the sense that participants having the opportunity to express their feelings in an emotionally safe environment made them feel valued. Check-in opportunities Casey described the peer mentoring experiences as opportunities to safely open up. She said, It allowed people to share thoughts they would probably keep to yourself because they're scared of what you might say or who they might go to to get in trouble or things like that. So, I think just opening up the space and allowing people to be able to express themselves freely without being judged, without worrying about being in trouble. Jack assessed the experience as one that felt more authentic, as well as appreciation for offering a place to check in and have someone check in with you. He shared, When you're working in this settingI guess you could say it is a maelstrom of just difficulties after difficulties...I admit, I mean, at the beginning I was skeptical. So actually, sitting through here and actually having basically a curriculum, like, a focus 91 each meeting and not just a way to just dump all your words. It's Here's what we're going to talk about and how does that correlate with how you've been? I feel like there's less of a disconnect now. I feel like they're trying to have us understand everyone's perspectives as well as what we can help each other with. So, it's definitely very nice to have. Charlotte also highlighted the check-in opportunities offered through peer mentoring and time with her mentor. She stated, I guess for me, check in is important because once you start a job, they check on you for maybe the first two weeks and then you get a 90-day review. But that consistent check in really helps with just reassuranceI want to know if I'm going down the right path or if it needs to be taken a different direction before too late to not let things fester. Jabari said the peer mentoring was a place for him to express what he was going through. He said, I think this program so far is so helpful and so impactful. Coming to sort of a place where you can actually share what you are going through, to express your opinion, and get feedback. Mentor relationships The mentors in the program played a key role in helping orient the participants when the stresses of the role overwhelmed. Jack said, You can get so lost in a job, especially this jobeven if [another] company has a program like this, if they're not telling them and reminding people on a more personable level. [At other places] You don't get a call from someone every other weekso I think it goes a long way to people knowing and understanding that they do have support. Emily agreed, saying, Yeah. for those really bad daysyou have that one person that just is like, hey, like it's going to be okay or how did your day go? 92 Nala summed up what both the peer mentoring and one-on-one experiences meant to her by saying that without them, she probably would have quit. She shared, It's been helpful. I could remember there's been two instances where it's been helpful. One was that I was working and just said, okay I will go tender my resignation. And one of those days, this meeting really helped change my focus. And what I picked up on during the meeting was, the [Circles of Control] exercise. And my mentor has also been helpful. The second time that I feel like, you know, I have to go. My mentor sent a text. He said, Hi. How are you doing? Is everything okay? You want to check in? He was really, really helpful to say the truth. He was helpfulI will say its one of the reasons why Im still here is because I have found some ways to help me manage the stress on the unit. Theme Three: Caregivers Value for Clients Similar to participants in stage one, the participants in stage two developed an appreciation and value for the clients they were serving. Casey spoke of the positive impact the clients had on her. She said, I think the relationship with the clients impacts me. It kind of makes me, like, I get a little bit closer to them because a lot of them think that they're somebody that you can't relate to or anything like that. And sometimes once you build a rapport with them and they see that they can trust youthey sort of start listening. And for me personally, I think the impact for me is it just allowed me to grow every day and learn something new about myself every day. Charlotte spoke about the enjoyment she got from getting to know her clients, saying, I enjoy my clients. I have 15 clients assigned to me and they're pretty dope. I really enjoy my clients. 93 Once you get to know them, they have so much personality. Emily spoke to the curiosity of the clients, stating I love their curiosity and I am always okay with them following me around because Im in a different role than their staff. I really like that. Theme Four: The Emotional Cost-Benefit Analysis In doing their work, the participants recognized that there were pros and cons that extended beyond the professional environment. Many of those experiences were able to be discussed with mentors in one-on-one mentoring. As was shared during the focus group, for those that remain in the program the personal benefits seemed to outweigh the emotional costs. Benefits In discussing the benefits of the program, Nala spoke to the welcoming atmosphere of the peer mentoring sessions. She shared, The room is welcoming. We know we're coming to have a good time. We love to go to these sessions, so it's always a good time to look forward to. Casey agreed that the investment in herself was an important aspect of the program. She detailed, I think just being able to take that hour of time away from caring for the clients. I think we need to take that hour of time away for your brain, reset your mind, you know, and go back in there with focus and knowing what you want to say now that you've heard everybody else's opinions. You've got resources. Youve got advice on what you could do. Just to be able to take that time out or find a way to reset your mind and come back relaxed and ready to go back again is important. Casey also thought the program helped her learn about the organization and what other jobs people do. She said, I think the program is good and helps you gain a better understanding of different people's roles and job positions. Emily agreed, What I like the best was actually being able to socialize with coworkers outside of the area you work and learning about each 94 other's job positions and how they're handling it and just collaborating and talking to those people. Taylor spoke about how the organization has helped her parent at home. She revealed, The experience, I believe, has helped at home with my own kidsI got to experience both these kids and my own. It taught me to be patient and let them express themselves. Emily was also using techniques she learned with her daughter. She described, I liked learning about like strategies to cope. You know, the tapping/mindfulness technique has really been a big thing for me. Ive even implemented that at home. Its something I can teach my daughter. Costs Carrying the emotional load of a bad day, building personal resiliency, and finding agency in the roles were discussed by participants. There seemed to be mixed reviews in understanding that the job was hard, but there was support for them while they were doing it. Jack shared, I've definitely had a lot of support from people in my unit, my manager, and my mentor. At the same time, I think it's just understanding the emotions behind everything and the actions and everything. There's been times where it has felt very bleak. It went far beyond just challenging and on those days the best we could do is try to be more positive at the end of the day. The bad days sometimes had to do with volume of work and other times had to do with challenging behaviors of clients in need. Charlotte said, I don't like feel that I can ever get caught up. While Casey shared, Last week was probably the most difficult since I've been hereand I spent almost all of my workday chasing someone outside. Its frustrating. Ola agreed, sharing, Last Sunday, I was so frustrated I almost quit. 95 Mentor Evaluation Ten mentors attended the focus group analysis session. They met for 90 minutes to discuss the programs impact on themselves, as well as their perceptions of the impact on the participants. They offered an analysis of the experience and their thoughts on how this program may have impacted retention. The themes for their time together centered on retention, building an emotionally supportive culture, the relationship investments, and an analysis of the Caring for the Caregiver program. Table 6: Stage Three Mentor Codes & Narrative Themes Code Theme/Essence of Phenomenon Code Frequency Retention Retention Influences 7 Team Emotional Support During Disorienting Experiences 5 Environment Emotional Support During Disorienting Experiences 5 Resilience Emotional Support During Disorienting Experiences 3 Mutual Benefit Relationship Investments 5 Program Analysis Program Analysis 8 Theme One: How the Program Influences Retention The mentors spoke about how they see the Caring for the Caregiver program supporting retention initiatives. This was described as the overarching message of this program demonstrating to new employees that they are not alone in their journey at the organization. Adam began, I think in terms of retention, it can be a very beneficial tool for that. Having somebody to reach out to to process a situation will bring them back down to baseline. Some of the things that you face in this industry, that you may not be familiar with, just having 96 somebody who has been here and potentially has gone through that. You know, people who have gone through that process I think can be beneficial in saying, Okay, that thing that I categorize as a 10 in my brain might actually be a 3 or 4 and let me take a deep breath. Eric added, And I would say it reduces the level of anxiety that people haveif you have someone that you can lean on, that you can talk to...it makes you feel comfortable. And once you can feel that comfort, it's easy for you to stay. Mike described the experience as a forced need, saying, I think a lot of our staff have really struggled. They come in and they're just not good at making those connections and nobody's reaching out to them to try to, like, force that. And this kind of forces some of that. And, you know, it's outside of some people's comfort zone because some people are very introverted. But when somebody is reaching out their hand and you know it's theresometimes just that, the fact that you know you have somebody you can talk to is enough. Theme Two: Need for Emotional Support During Disorienting Experiences Like the other stages in the study, mentors described the need for building an emotionally supportive culture to help sustain human service workers during disorienting experiences. Team The need to feel a part of a group was a concept the mentors discussed. Mike said, There is a community here and an element of family here. I think everybody doesn't feel connected to that, which is kind of sad. And I think this [program] is, like, maybe a step in that direction that maybe help people feel they have thatI've met some of the best 97 people that I've ever known working alongside people here, and I have some great friendships and relationships with a lot of folks here. Chrissy saw the experience as one that made the team even larger. She described, It's good to know that you don't have to stay in your circle to get advice from somebody else. You know, it's like you can go with somebody else. Environment Mentors assessed that being in a therapeutic environment also seemed to have an impact on the program, as well as the experiences of the mentors being human service workers themselves. Adam joked about getting paid for the community service he provides, saying, I think overall the experience has been very fulfilling. The company and my staff align on the values of trying to be of service. I tell people sometimes people call it community service, but we get paid for it. So, in that regard, its been very good for me and my personal growth. Eric added that the environment for him resulted in feelings of appreciation due to a personal tragedy. He described, When my apartment caught fire in March of this year, the kind of support that I had like, I was getting a call from my manager checking in on me. It made me feel like, okay, this is not just a place to work. For two weeks they got me a hotel and everything like that. I sleep on a very comfortable bed they bought me. I feel like a team. What I'm saying is it's one thing to work and it's another to appreciate where you work. Resilience Eric spoke about how he was reminded of the resilience he built in himself through this program. He shared, Personally, I have grown in a lot of ways by working here. My patience is 98 much better in dealing with not just the kids, but with the staff. Sandy agreed that the resilience built in the role helped her personally. She stated, I agree with you. My world was rocked last December. I thought I was going to lose my husband in a car accident. And thank God I didn't. He is still very much in recovery. And I feel like I'm going to get emotional because [the organization] has just been such a huge part of my life. Hope described the resilience-building initiative as one that was not only benefiting the individual, but also the organization. She summarized her assessment by saying, I think we've come a long way in the five years that I've been here, because when I first started, this is not where we were at. So, we've made a lot of really great progress and that is positive. In fact, I think we're learning a lot about ourselves and about these kids. And our role is ever changing very, very quickly. And that means we have to figure out more support for that. So, I think at least from my experience, I think it's great. Theme Three: Mentors and Participants Investing in Each Other Mentors spoke about the value of investing in relationships with new employees and the benefits they received personally through the mentoring process. Mutual benefit Adam described his relationship with his participant as one that is a mutually beneficial experience. He said, My guy is super. Hes proven that he's a very calm, a very even-keeled guy. I didn't know what to expect. I mean, I don't necessarily like to talk about my feelings, but he was a nice surprise. He went through a suspension. You would have expected him to be somebody that would have come out of that a little bit jaded and upset, but he went right back to work. Of course, he had his concerns about how it happened, but we were able to 99 talk about what the process looks like. It's something that has been a give and take. He's been able to pour into me as much as I think I've been able to give to him. Chrissy also shared a mutually beneficial experience stating, Mine is almost the same. She was phenomenal. We kind of had the same experience of losing sisters. And that kind of made me feel like God put her in my life at the right time and I was put in her life at the right time because that was something that we can use to connect with each other. We both gave each other advice on how to get through that. I think that opened a lot of trust between the both of us that we could have that in common. Caras relationship with her participant was one that grew over time but is something they both value enough to continue outside of this program. She shared, I have to say, mine was hard at first. She didn't want to open up. And I had to keep going back to her and doing everyday checks on her. Now she will text me or call me and ask me questions when there is a crisis on the unit. Now we are wanting to continue outside of this program. Like Caras relationship, Sandys relationship with her participant developed trust over time. In speaking to the trust factor in their relationship, she said, I think there's an element of trust here, too. Like from the get-go, we had like that quick meeting with them where we were just getting to know them. And we're trying to build that relationship before we even ask anything of them. This mentor program allows us to build that trust. 100 Theme Four: Program Analysis from Mentors Perspective The mentors spent time considering whether the Caring for the Caregiver program would offer benefit to the organization upon completion of the study. Overall, everyone agreed that it was important to do something or offer something with intentionality and purpose behind it. Eric shared his support by saying, I would say we should continue on with this because, looking at what everybody said, one way or the other we all have been connected to someone here. I think the intentionality of the program is a good thingits what matters. Chrissy agreed, I think its a great idea. Like, I think it's something you should continue. And there's some things [from the program manual] that I've learned to use with everyone. Solomon offered his positive review of the program manual, as well. He said, I really liked that it was well structured. I liked the manual. And I also liked an exclusive section with the program where we provided feedback. I just feel like everything was done for me; you know. I feel like everything was done for me, and all I had to do was support it. In her analysis, Sandy offered an idea to innovate if the program were to continue. She suggested, I would have loved to have maybe reached out to their supervisor to kind of double check like, Hey, I wanted to reach out to let you know that I am mentoring so and so. I'm interested to see if maybe you're seeing the same thing that I see. Sandy also shared that she wished her participant had been in her program line or department. She said, I feel like if I had someone that was really in my group or in my department, I feel like I would have been able to connect maybe better with them. 101 Facilitator Debrief The co-facilitators met on Zoom a week after the focus groups finished. Their discussion was part free-flowing conversation and part question and answer. Without naming it adaptive work per se, both facilitators spoke about how special it was that the group was being supported and supporting each other through the study. There was agreement on the overall excitement about working on a solution. Kim shared, It's such an exciting time to think about being a part of the solution of something we all know to be evidence. Retention is something that if we can figure some things out around it, we could be a healthier and stronger community. She added, Whats going to help someone stay is the ability to have resiliency and to be able to see the long game. Sarah added, We're learning from them just as much as they're learning from us. Like, if the web of support extends deeper, you feel more secure. This is a safe place. They're going to and we're going to figure it out. Whatever the thing is, we're going to get through it. Whatever the thing is that makes it feel like it's worth staying through the bumps, if that makes sense. Beyond excitement and motivation on working towards a solution, the facilitators observed that relationship building and building trust over time were key components to the program. Kim shared, You have to know someone, and someone has to know you to really help you land in a place where you will be successful in believing that's someone's intention. Sarah added, 102 I think there was ownership. And I also think that the trust got built. Because the last thing there we ended with [in the last session] was the meditation moment. And boy, to see those folks go from nobody having their eyes closed in the first one and in the end, everybody was like, Oh, goody, ready? Let's do that. is my favorite. That's my favorite thing that happened the whole timeIt's really a high degree of trust to close your eyes in front of another adult so you'll be safe physically and psychologically. It's fascinating. Finally, the facilitators shared that they felt the real magic of the peer mentoring sessions was consistency. At the end of the participant focus group, one participant asked if they could continue meeting as a peer group on a quarterly basis. Sarah said, I think that is one of my favorite things. I think that the driving force behind can we get together quarterly was that they got to see consistency right from the very beginning. Kim added, We kind of filled the gap for them while that was being established because that takes time. There's so much that they're learning that I feel like the program provided the stability to help them stay until they could gain that trusting relationship and understand all of the new in their environment. Then, the leadership and the team comes in. We were the space that helped to just get them a place to land as that was being transferred. Sarah agreed. Sometimes, she said, the great things that we experience come out of the hard things. 103 Pre-Test and Post-Test Findings As a phenomenological study, the emphasis of this research was on the qualitative exploration of lived experiences of human service professionals. However, as a way to triangulate the data, pre-tests and post-tests were given to participants during the data collection phase to see if any additional learning about their experiences could be gleaned with a quantitative approach. The two instruments used were the Work and Meaning Inventory (Appendix J) and the Perceived Person-Environment Fit Scale (Appendix K). The pre-tests were given on the first day of research collection during stage two and the post-tests were given on the last research collection day during stage two. Fourteen participants attended the final research collection day, so only their post-tests could be compared to their pre-tests. This is a relatively small sample size, so caution is exercised not to draw too firm conclusions or hold too tightly to the results. Work and Meaning Inventory The Work and Meaning Inventory (WAMI) is an instrument that measures meaning in work through three scales positive meaning in work, meaning making through work, and greater good motivation. The instrument provides ten statements and asks participants to rate their agreement on a scale of one to five (with one meaning absolutely untrue and five being absolutely true). Overall scores could range from 13-49. As described by the creators of the WAMI, Steger et.al (2012), the positive meaning score reflects the degree to which people find their work to hold personal meaning, significance, or purpose. The meaning making through work score reflects the fact that work is often a source of broader meaning in life for people, helping them makes sense of their lived experience. The greater good motivations score reflects the degree to which people see that their effort at work makes a positive contribution and 104 benefits society. All the scores can be tallied to get the overall meaningful work score, which reflects the depth to which people experience their work as meaningful and as something they are personally invested in. Low scores on any of the scales reflect an absence in work meaning, and may be predictive of poor work engagement, low commitment to ones organization and intentions to leave, low motivation, a perceived lack of support and adequate guidance from leadership and management. Table 7: Work and Meaning Inventory (WAMI) Elements and Descriptors Element Being Scored What the Score Reflects Evidence of Statistical Significance Positive Meaning Through Work The degree to which people find their work to hold personal meaning, significance, or purpose. Meaning Making Through Work This score reflects the fact that work is often a source of broader meaning in life, helping them make sense of their life experiences. No Greater Good Motivators The degree to which people see that their effort at work makes a positive contribution and benefits others in society. Yes Overall Scores for WAMI The Meaningful Work score reflects the depth to which people experience their work as meaningful, something they are personally invested in, and which is a source of flourishing in their lives. No No Participants in this study were measured on their meaningfulness at work before and after participating in the Caring for the Caregiver intervention. A paired samples T-test was selected for statistical analysis to compare the post-test results to the pre-test results of the fourteen participants. Bevans (2023) recommends using a paired samples T-test for this purpose because a paired samples T-test is defined as a test that compares the means of groups before and after they participate in an intervention. The T-test calculates a probability value (p-value) that is then compared against the standard alpha, which in social science research is set at .05. 105 The data shows that the intervention did not have a statistically significant impact on the pre-test versus post-test scores. Said another way, any differences in the scores from pre-tests to post-tests were more likely a product of chance rather than the Caring for the Caregiver program. This was determined by comparing the individual category scores and the overall scores. Extracting the data for positive meaning through work, the results of the pre-test (M = 17.2, SD = 2.3) and the post-test (M = 17.8, SD = 1.8) indicated no statistically significant impact, t = -1.1, p = .273. Looking at the meaning making through work scores, the pre-test (M = 13.1, SD = 1.9) and the post-test (M = 13.1, SD = 1.3) also indicated no statistically significant impact, t = -0.1, p = .905. Finally, the overall scores of the pre-tests (M = 43.7, SD = 4.9) versus the post-tests (M = 42.9, SD = 4.2) indicated no statistically significant impact, t = 0.9, p = .394. The data does suggest that there was one statistically significant finding. There is a relationship between the Caring for the Caregiver intervention and the change in score for the greater good motivators category. In looking at the mean score for greater good motivators, the post-test scores (M = 11.9, SD = 2.5) decreased from the pre-test scores (M = 13.4, SD = 1.7), t = 3.1, p = .009. Hence, it appears that the Caring for the Caregiver program did have an impact on the greater good motivators. What is interesting is that the scores went down, which becomes a compelling data point for further consideration. 106 Figure 3: Paired Samples T-Test for the Work and Meaning Inventory Perceived Person-Environment Fit Scale The Perceived Person-Environment Fit Scale (PPEFS) is an instrument that consists of four measures: person-job fit, person-organization fit, person-group fit, and person-supervisor fit. Developed by Caplan et. al (1980), the scale asks employees to provide responses to parallel sets of items covering the four job dimensions the job itself, the organization, the workgroup, and the supervisor. Participants rated from a 1 (no match) to a 7 (complete match) for the 26-question survey. Similar to the WAMI, a paired samples T-test was conducted to compare the overall posttest results to the pre-test results of the fourteen participants. Then, additional paired samples Ttests were run for each of the four job dimensions. Like what was found with the WAMI data, any differences in the scores from pre-tests to post-tests of the Perceived Person-Environment Fit Scale were more likely a product of chance rather than a product of the Caring for the Caregiver program. The data from all five tests indicates there was no statistically significant relationship 107 between the Caring for the Caregiver program and responses to the Perceived Person Environment Fit Scale. When comparing pre-test (M = 156.1, SD 16.6) and post-test scores (M = 149.5, SD = 23.2), the intervention did not have a statistically significant impact on the overall perceived fit the participants felt with the organization, t = 1.1, p = .299. Figure 4: Paired Samples T-Test for Perceived Person Environment Fit Scale A deeper dive into the data did not uncover statistically significant findings related to the perceived fit between the person and the job itself. When comparing the person-job fit pre-tests (M = 23.4, SD = 3.6) to the person-job fit post-tests (M = 22.9, SD = 3.9), changes in scores could not be attributed to the Caring for the Caregiver program, t = .4, p = .690. Figure 5: Paired Samples T-Test for Person-Job Perceived Fit The data also did not uncover statistically significant findings related to the perceived fit between the person and the organization. When comparing the person-organization fit pre-tests 108 (M = 43.4, SD = 4.4) to the person-organization fit post-tests (M = 40.7, SD = 7.4), changes in scores could not be attributed to the Caring for the Caregiver program, t = 1.4, p = .178. Figure 6: Paired Samples T-Test for Person-Organization Perceived Fit Further, the data did not reveal statistically significant findings related to the perceived fit between the person and their workgroup. When comparing the person-group fit pre-tests (M = 60.1, SD = 6.2) to the person-group fit post-tests (M = 57.1, SD = 9.9), changes in scores could not be attributed to the Caring for the Caregiver program, t = 1.4, p = .199. Figure 7: Paired Samples T-Test for Person-Group Perceived Fit Finally, the data did not detect statistically significant findings related to the perceived fit between the person and the relationship with their supervisor. When comparing the personsupervisor fit pre-tests (M = 29.1, SD = 4.7) to the person-supervisor fit post-tests (M = 28.8, SD = 4.4), changes in scores could not be attributed to the intervention, t = .198, p = .846. 109 Figure 8: Paired Samples T-Test for Person-Supervisor Perceived Fit Caregiver Retention Prior to implementation of this intervention, new employee retention data was collected. For the previous six months, the 30-day retention average was 78%, while the 90-day retention average was 62%. Looking back over one year, the 30-day retention average was 80%, while the 90-day retention average was 65% (Internal Document, 2023a). The Caring for the Caregiver participant retention rate was higher at all interval measures. Retention at 30 days was 100%, while retention at 90 days was 86.5%. Table 8: Caring for the Caregiver Participant Retention Cohort 30 Days 60 Days 90 Days 1: July 10, 2023 100% 86% 73% 2: July 17, 2023 100% 100% 100% 93% 86.5% Blended Retention Rate 100% Four participants left the organization during the intervention window three resigned and one was terminated. While they were enrolled in the program, none of the four participants attended any peer mentoring sessions. The first departure was on August 17, 2023. Participant Mackenzie did not show up for on-the-job training and sent her manager a resignation via text 110 message. Her assigned mentor was not able to connect with her via phone or email. The second departure was on August 22, 2023. Participant Zola was terminated due to a policy violation. She had been speaking with her mentor but had not attended a peer mentoring session due to a conflict in her shift schedule. The third departure was on September 9, 2023. Participant Ada resigned. She had spoken with her mentor; however, could not attend peer mentoring sessions because she had class during that time. The final departure was on October 9, 2023. Participant Aidan did not attend any peer mentoring sessions, nor did he communicate with his mentor. Outside of their first interaction when they met during NEO, there was no communication between the two. While not part of the retention measure, it is worth noting that one mentor also left the organization during the intervention window. His family relocated during this time, and his participant was reassigned to a different mentor. Another mentor took a leave of absence during the intervention window due to a death in the family. She asked to have her participant reassigned, which was accommodated. Sadly, one facilitator and one mentor each had their mother pass away during this time. While they each stepped away for their respective bereavement leaves, they both returned to the program and did not request nor need participant reassignment. 111 Cost Analysis The costs for this program included printing, supplies, hospitality costs, and a subscription for the qualitative SAAS software. Table 9: Caring for the Caregiver Program Costs Expense Amount Printing 1,619.34 Software 617.00 Supplies 95.38 Lunch Stage One Focus Group 722.77 Lunch Stage Three Focus Groups 665.48 Peer Mentoring Snacks 193.20 Total $3,913.17 According to Navarra (2022), the Society for Human Resource Managements benchmarking data estimates that the average cost to hire a new employee is $4,700. At that rate, this program costs less than the estimated cost to hire one new employee. At the same time, retention for those enrolled in this program was 21.5% higher than the previous average for the organization, which was 65%. As it relates to this study, a 21.5% higher retention rate would equate to retaining five extra employees, thereby saving the organization $23,500 in hiring costs based on the benchmarking data provided by Society for Human Resource Management. 112 Chapter 5: Conclusions Revisiting the social constructivism theory, this phenomenological study highlighted the collaborative nature of learning. The participants in this program created a shared culture with shared artifacts and meanings. From the beginning, this study set out to answer two questions: How do human service professionals experience working in the ID/DD environment? In what ways does the Caring for the Caregiver Program influence elements of retention for human service professionals? As a result of the study, the impact of the lived experiences on the participants was communicated via themes. The most common shared experience among all participants and across the stages of the research was the need for emotional support during disorienting experiences. Many participants indicated that the intervention of the Caring for the Caregiver program, applied during stage two, aided in providing that emotional support as new employees were being introduced to the culture of serving clients with intellectual and developmental disabilities. A second theme across multiple stages of research was the need for participants personal values to align with the mission of the organization. Living out ones values in the workplace led to experiences of observation, learning, then relationship development with the clients being served. While the emotional costs of the work were noted as high, for most participants, the costs were worth the benefits of staying in the system to continue working for the cause. Aside from the qualitative themes developed throughout the research, the actual retention of the participants is worthy of noting. Compared to benchmark data from the previous year, retention improved by 21.5% for the participants as compared to peer New Employee Orientation groups. While the limited quantitative data does not support the intervention having a 113 statistically significant impact, the qualitative data combined with the raw retention data suggests progress. The intervention was designed to influence elements of retention, and retention was improved. As presented in the qualitative data, the most powerful aspects of the intervention for the stage two participants were simply knowing that someone was rooting for them, that they had consistent touch points, and were offered opportunities to be vulnerable without fear of judgement by supervisors or others in the organization. Having someone (e.g., their mentor) believe in them also influenced the participants experiences. As Amara shared, Ive gotten a lot of support from my mentor. She was there from day onechecking in, calling, texting, and making sure I am okay. This lived experience supports the work of Lent et al. (2002), who introduced their social-cognitive career theory to explain that for employees, interests do not develop when individuals do not form strong self-efficacy and positive outcome beliefs. Speaking to her own positive outcome beliefs, Charlotte deduced, I really enjoy my clients. I learned their cuesIm very personable. I really focus on their likes and what they enjoy doing, and thats created some very, very good experiences for me. Stella agreed saying, Honestly, [the clients] make my day better. Any time I get stressed, or I need to, I can just go take time and hang out with the kids. And I really like just hanging out with them. Having somewhere to go (e.g., peer mentoring) when the work with clients was challenging was also highlighted as important during evaluation. Ola described the positive benefit of the peer mentoring experience by saying, You know you have a place you can go to talk to someone about stress. It is so encouraging. This assessment ties back to the Klaver et al. (2020) study that found staff self-efficacy and access to the supervisor/social support system seemed to be factors that influenced staff well-being. Nala described having difficulty 114 connecting with a client and bridging that gap by sharing something she is good at with the kids. She shared that one client with escalated aggression approached her, and she deescalated the situation with music. Nala said, I love to singand this child was crying. I said, I think I can find a way to deal with her. And I started playing music. So, we got through one song, and I said, lets dance! That act created a spontaneous dance party on the unit, which now happens daily. Based on the evaluation of the intervention in stage three, participants expressed gratitude for the intentionality of and the purpose behind the Caring for the Caregiver program. Casey shared, Being able to take that hour of time away from caring for clientsto reset your brain, reset your mind, and go back with focus knowing what you want to say now that youve heard everyones opinions. Ive gotten resources and advice. Holland (1996) suggested individuals enter environments because of their personalities and remain in those environments because of the reinforcements and satisfactions obtained through the interactions in that environment. As described by longer-tenured participants in stages one through three, the benefits of the work have outweighed the costs. From personal friendships to life lessons to the value of client relationships formed, these staff experienced and communicated job satisfaction. Participants in stage two (to whom the intervention was applied) were able to begin to communicate these reinforcements and satisfactions, as well, when asked during their stage three evaluation. Taylor spoke to the personal benefits of working for the organization saying, The experience has helped at home with my own kids. Emily described feelings of motivation, There are so many accomplished people here, and it just drives you to want to keep going. You know, being more accomplished for yourself. In a call back to the initial diagnostic work of this study, there were four unique experiences that informed the retention-decision process for human service professionals in the 115 organization. These experiences were peer support, supervisor belief that they could do the job, feeling special, and having a sense that no one else could or would step up for the clients if they were to vacate their roles. Newer employees in this study also shared the need for peer support and having someone believe in them. Charlotte shared, If it wasnt for my team and my mentor, I think those challenging days wouldve been like, maybe I need to reevaluate my position or this job. Instead, it turned into, okay, I just need to get better at this. I need to figure out my niche. Further, they began noting difference making experiences that highlighted they were a special contributor to the organization. During stage one, Stephanie said, I love doing small things with great care. They make a difference in the lives of the people I work with. Along those lines, Femi noted, I discovered they like to cook food. So, I do more of the cooking so that they can help me, you know, cook for them. They have been really very good to me. All feelings and experiences included, the most practical implication of this research for the organization is that retention was improved significantly. As Nala concluded, without the Caring for the Caregiver program, she most likely would have quit the organization. Casey agreed and added that the program allowed her to grow and learn something new about herself every day. I did not expect that the Caring for the Caregiver program would have as significant an impact on retention as it did. While unexpected, it allowed for a deeper look into why people would choose to stay in an environment that is so challenging. As a part of this deeper dive, the only statistically significant finding in the quantitative data was that the greater good motivations score went down. Steger (2012) states the greater good motivations score reflects the degree to which people feel their contributions at work benefits others in society. The pre-test scores were quite high, leaving very little place to go other than down. It appears that participants entered the 116 system with high expectations, and many found that, upon experiencing the environment, they were disappointed. A look at the work of theorists in decision research, particularly disappointment theory, can help explain this phenomenon in human services work. In his decision analysis research, Bell (1985) explored the implications of disappointment caused by comparing the actual outcome of a lottery to ones prior expectations. Specifically, he found that winning the top prize in a $10,000 lottery may leave one much happier than receiving $10,000 as the lowest prize in a lottery. He explored decision-making under uncertainty, including the implications of disappointment. Disappointment is a psychological reaction that comes from comparing an obtained outcome with a better outcome that might have resulted from the same choice being made (e.g., disconfirmed expectancies). While out of scope for this research, a future study of disappointment theory with human service worker experiences would be interesting. Other surprises or unexpected experiences were how few people complained about pay in this low-wage industry. While it was mentioned for longer-tenured staff, no one new in the system mentioned pay as a detriment to staying in the organization. Additionally, I was surprised how motivated longer-tenured staff appeared to be to help make improvements or changes to the system. Not only were there significant expressions of gratitude during stage one, but the mentors who volunteered during stage two took these roles very seriouslyoften leaning on each other to consider ways to support their mentees. Mentors Solomon and Daniel worked together for several weeks to navigate conflict between their two mentees on the unit. Mentors Cara and Chrissy worked in tandem with their mentees when client behaviors spiked on their unit, noting that having the extra support and encouragement built a bond between the four participants. 117 A final pleasant surprise was the description of the mutually beneficial relationship between the mentors and mentees. In a tip of the hat to human centered design, the Caring for the Caregiver program presented opportunities for mutual flourishing and co-creation throughout the program. Based on an assessment by the organization, it is possible that a Caring for the Caregiver program 2.0 might be adopted. Should that be the case, a couple of suggestions for improvements would be offered. First, a couple of technical improvements could be: 1) The calendar provided to mentors and their participants seemed confusing at first and not everyone was clear on where they needed to be when, so this would be streamlined. 2) The participants often forgot to bring their guides. Often that meant making copies of the pertinent pages for the weeks programming. A new version would consider fillable forms and digital-only copies, such that they could be accessed from anywhere. 3) In this first iteration, there were a few mentors and participants paired on opposite shifts, making communication a bit more difficult. This points to another change in aligning shifts with participants and mentors. Beyond those technical fixes, there are two other areas that might improve the overall experience of participants in the Caring for the Caregiver program. The first would be to have more active involvement from and with the supervisors of participants. This was a suggestion from a mentor who wished she had had a closer connection with the supervisor, such that they could make sure they were aligning around needs. Finally, it will be important for the organization to figure out how to catch the first act of client aggression with new employees. When a client has a behavior or is escalating in violence necessitating a physical restraint, an incident report is filled out and turned into the performance 118 and quality improvement team for review. The employee who fills out the form is the one who is noted in the experience, even though several other employees might be involved. Aside from follow up on protocol, there is no formal check-in to determine how the employees mental health is after a traumatic client experience. This opens a gap to miss a new employee being involved in a heightened emotional experience. As Wilson and Britt (2020) found, helping fatigued workers after harm has been done is less effective and sustainable than improving the personal and management skills of employees prior to the experience of mental health symptoms. Their study demonstrates the importance of organizational interventions designed to help employees better respond to stressors in a healthy way. In speaking of the peer mentoring sessions, Emily said, If youre on the edge of okay, Im going to quit these check-ins really help with that because you can express that to somebody without feeling like youre going to be retaliated against. Then, they can help you figure out why you feel that way instead of just quitting. Based on the results of this study and observations throughout, there are several implications for future research. One area of future research could be the early-on commitment of supervisors and the successful retention of new staff. As this research found, supervisor commitment varied based on guesses about whether the new employee could be sustained by the system. If supervisors were committed from day one, would that make a difference? The next area of future research is based on an observation made about mentors and their excitement to be in the program. It is interesting to consider whether the act of simply being a mentor in the organization might support greater engagement and retention. A third area of exploration is based off the research of Kaprkov et al. (2018) who found that resilient workers are healthier 119 and less likely to quit, it would be interesting to apply a resilience assessment measure when hiring new human service workers to see if this enhances their resilience and overall retention. Finally, and importantly, an area of future research could be an exploration of whether client care improves if staff retention improves. 120 Personal Reflection and Implications for my Leadership Practice This research was a powerful experience for me, and one that reminded me of the need for greater appreciation towards human service workers. I started the study citing my reverence for these workers and I ended the study with even more appreciation for their work. These people are at times lifesavers, best friends, stand in guardians, teachers, therapists, targets, believers, doubters, and the backbone behind the important work in disabilities industry. The industry is not built to meet their needs, rather it is so client-focused that these needs are overlooked at great expense. Unless they have a good friend at work or lucked into a great supervisor, the system is not built to check in on them. There are several elements of this study that will stick with me going forward. The first is that there is no real magic to developing bonds with others. It takes consistently showing up for others, letting them know you care and that you have their back. When that happens, a bond is formed, and that bond is critical to the entire system functioning properly. The second element is that it takes time to build trust and form relationships. Trust forged in traumatic experiences might speed up the process a bit, but it takes timeand for some people, the holding environment is not stable enough for them to build the trust. A third element that will remain with me is the lifesaving element of this work. Unlike other industries, where people knowingly accept that they are stepping into a potentially lifesaving role (doctor, EMT, police officer, military personnel, etc.), the human service worker is surprised to learn that being in the daily life of a person with an ID/DD diagnosis may mean stepping into danger or protecting that client from danger. As evidenced in stage one of this research, a participant recalled a harrowing experience. She said, We just saved somebodys life and then went right back to work without someone even checking on us. The system is built for the client, but it needs to be rebuilt for 121 sustainability with the human service workers mental health in mind, as well. A final element that will stay with me is the satisfied feeling I have that the group of participants in stage two those to whom the intervention was applied want to stay together as a peer mentoring group. At the conclusion of their evaluation session, they asked about and made plans for future quarterly meetings to check in with each other and continue learning together. To me, this feels like the practice and purpose of adaptive leadership. 122 References Ahern, K. J. (1999). Ten tips for reflexive bracketing. Qualitative Health Research, 9(3), 407 411. American Association on Intellectual and Developmental Disabilities. (n.d.). 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Work-related stress and well-being of direct care workers in intellectual disability services: A scoping review of the literature. International Journal of Developmental Disabilities, 67(1), 122. https://doi.org/10.1080/20473869.2019.1582907 Spencer, E. A., & Mahtani, K. (2021, November 20). Hawthorne effect. Catalog of Bias. https://catalogofbias.org/biases/hawthorne-effect/ Steger, M. F., Dik, B. J., & Duffy, R. D. (2012). Measuring meaningful work: The Work and Meaning Inventory (WAMI). Journal of Career Assessment, 20(3), 322337. https://doi.org/10.1177/1069072711436160 Stiffler, K. L. (2008). Direct support staff perceptions of frontline supervisors skills: Correlation with organizational commitment and intent to leave. Dissertation Abstracts International: Section A. Humanities and Social Sciences, 68(9-A), 3958. St. John, M. (2022, May 13). How to become a direct support professional. Forbes. https://www.forbes.com/advisor/education/become-a-direct-support-professional/ 134 Tellez, R. (2014). Testing the unfolding theory of turnover: development of an exit survey (1560893961) [Masters thesis, San Jose State University]. ProQuest Dissertations and Theses Global. http://www.proquest.com/dissertations-theses/testing-unfolding-theoryturnover-development/docview/1560893961/se-2 White, M. (2018). Calling in the United States: prevalence and the role of source (2055362568) [Masters thesis, Colorado State University]. ProQuest Dissertations and Theses Global. http://www.proquest.com/dissertations-theses/calling-united-states-prevalence-rolesource/docview/2055362568/se-2 Wilson, C. A., & Britt, T. W. (2020). Living to work: The role of occupational calling in response to challenge and hindrance stressors. Work & Stress. Advance online publication. https://doi.org/10.1080/02678373.2020.1743791 Wrzesniewski, A., McCauley, C., Rozin, P., & Schwartz, B. (1997). Jobs, careers, and callings: Peoples relations to their work. Journal of Research in Personality, 31(1), 2133. https://doi.org/10.1006/jrpe.1997.2162 Yama, M. (2018). Calling at work: Relationship to engagement, job satisfaction, and turnover intent (2166266993) [Masters thesis, San Diego State University]. ProQuest Dissertations and Theses Global. http://www.proquest.com/dissertations-theses/callingat-work-relationship-engagement-job/docview/2166266993/se-2 Young, J. (2012). Job embeddedness theory: can it help explain employee retention? (1625) [Doctoral dissertation, University of Louisville]. ProQuest Dissertations and Theses Global. https://doi.org/10.18297/etd/1625 Young, J. (2021, October 31). Too big to fail. Investopedia. https://www.investopedia.com/terms/t/too-big-to-fail.asp 135 Zablotsky, Benjamin, Black, Lindsey I., Maenner, Matthew J., Schieve, Laura A., Danielson, Melissa L., Bitsko, Rebecca H., Blumberg, Stephen J., Kogan, Michael D., & Boyle, Coleen A. (2019). Prevalence and Trends of Developmental Disabilities among Children in the United States: 20092017. Pediatrics, 144(4), e20190811. https://doi.org/10.1542/peds.2019-0811 Zhou, W. (2021). Work meaningfulness: examining S-ABC needs-supplies fit and work as jobs, careers and callings (2641867265) [Doctoral dissertation, Southern Illinois University Carbondale]. ProQuest Dissertations and Theses Global. http://www.proquest.com.forward.marian.edu/dissertations-theses/work-meaningfulnessexamining-s-abc-needs/docview/2641867265/se-2 136 Appendix A Email Solicitation for Stage One Participants Dear [client-facing human service professional], As part of a research study on retention, we are conducting a focus group with clientfacing employees who have been employed at the organization for at least one year. As someone who fits that category, you are in an ideal position to give us valuable first-hand information from your own perspective. The focus group will be held on [date, time] at [location]. The focus group takes around 90 minutes and is very informal. We are simply trying to capture your thoughts, perspectives, and experiences of being an employee at [the organization]. Your responses to the questions will be kept confidential. This is a voluntary program, and you will be paid your normal hourly wage for your time spent participating in this study. After the focus group concludes, you will be asked if you would like to provide further input into the study. Further input is not required. Your participation will be a valuable addition to our research and findings could lead to greater understanding of how employees experience our culture, their jobs, and the retention efforts of the organization overall. If you are interested in participating, please email [researcher] at [researcher email] and indicate your interest. Please let me know if you have any questions. Thank you in advance, [Researcher] 137 Appendix B Presentation Call for Participants 138 139 140 Appendix C Focus Group Consent Form Stage One Purpose You have been invited to participate in a focus group as part of a doctoral research study at Marian University. The purpose of this focus group is to capture your thoughts, perspectives, and experiences of being an employee at [the organization]. The information learned in this focus group will be used to develop programming for new employees at [the organization]. Procedure This focus group is voluntary. As part of this study, you will be placed in a group of up to 12 individuals. A moderator will ask you several questions while facilitating the discussion. As approved through Marian Universitys Institutional Review Board, this focus group will be recorded, and notes will be taken. However, your responses will remain confidential, and no names will be included in the final report. Your responses will not be shared with your supervisor and will have no bearing on your employment standing. You can choose whether to participate in the focus group, and you may stop at any time during the study. Please note that there are no right or wrong answers to focus group questions. Out of respect, please refrain from interrupting others. However, feel free to be honest even when your responses counter those of other group members. Confidentiality Should you choose to participate, you will be asked to respect the privacy of other focus group members by not disclosing any content discussed during the study. A researcher will analyze the data, butas stated aboveyour responses will remain confidential, and no names will be included in any reports. Your identity will be known to other group participants and the researchers cannot guarantee that others in the group will respect the confidentiality. Please keep all comments made confidential and do not discuss what happened during the session with anyone outside the study. Contact If you have any questions or concerns regarding this study, please contact the Marian University Institutional Review Board at [email]. I understand this information and agree to participate fully under the conditions stated above. Signature: ________________________________________ Printed Name:_____________________________________ Date:__________________ 141 Appendix D Caring for the Caregiver Consent Form Stage Two Purpose You have been invited to participate in a unique program for new employees as part of a doctoral research study at Marian University. The purpose of this study is to capture your thoughts, perspectives, and experiences of being an employee at [the organization]. The information learned during this study will be used to analyze the Caring for the Caregiver program at [the organization]. Procedure This is a voluntary program. As part of this study, you will be placed in a cohort group based on your hire date. A facilitator will provide additional training during your orientation period. Then, you will have 6 follow-up group mentoring sessions during your first three months of employment. During a final session, a moderator will facilitate a focus group and ask you several questions. As approved through Marian Universitys Institutional Review Board, these program sessions will be recorded, and notes will be taken. However, your responses will remain confidential, and no names will be included in the final report. Your responses will not be shared with your supervisor and will have no bearing on your employment standing. You can choose whether to participate, and you may stop at any time during the study. Confidentiality Should you choose to participate, you will be asked to respect the privacy of other cohort members by not disclosing any content discussed during the study. A researcher will analyze the data, butas stated aboveyour responses will remain confidential, and no names will be included in any reports. Your identity will be known to other group participants and the researchers cannot guarantee that others in the group will respect the confidentiality. Please keep all comments made confidential and do not discuss what happened during the session with anyone outside the study. Contact If you have any questions or concerns regarding this study, please contact the Marian University Institutional Review Board at [email]. I understand this information and agree to participate fully under the conditions stated above. Signature: ________________________________________ Printed Name:_____________________________________ Date:__________________ 142 Appendix E Focus Group Consent Form Stage Three Purpose You have been invited to participate in a focus group as part of a doctoral research study at Marian University. The purpose of this focus group is to capture your thoughts, perspectives, and experiences of being an employee at [the organization]. The information learned in this focus group will be used to analyze the Caring for the Caregiver program at [the organization]. Procedure Your participation is voluntary. As part of this study, you will be placed in a group of up to 10 individuals. A moderator will ask you several questions while facilitating the discussion. As approved through Marian Universitys Institutional Review Board, this focus group will be recorded, and notes will be taken. However, your responses will remain confidential, and no names will be included in the final report. Your responses will not be shared with your supervisor and will have no bearing on your employment standing. You can choose whether to participate in the focus group, and you may stop at any time during the study. Please note that there are no right or wrong answers to focus group questions. Out of respect, please refrain from interrupting others. However, feel free to be honest even when your responses counter those of other group members. Confidentiality Should you choose to participate, you will be asked to respect the privacy of other focus group members by not disclosing any content discussed during the study. A researcher will analyze the data, butas stated aboveyour responses will remain confidential, and no names will be included in any reports. Your identity will be known to other group participants and the researchers cannot guarantee that others in the group will respect the confidentiality. Please keep all comments made confidential and do not discuss what happened during the session with anyone outside the study. Contact If you have any questions or concerns regarding this study, please contact the Marian University Institutional Review Board at irb@marian.edu. I understand this information and agree to participate fully under the conditions stated above. Signature: ________________________________________ Printed Name:_____________________________________ Date:__________________ 143 Appendix F Focus Group Protocol & Discussion Guide Stage One Introduction, Process, Consent Ground Rules Ground rules and group norms are established to ensure mutual respect, consideration, and a supportive atmosphere for discussion. Introductions Questioning Sequence Introduce yourself. Review the studys purpose, how long you expect the focus group to take (90 minutes), and the plans for using the results. Note that the interviews will be recorded and that you will keep participants identities confidential. Distribute consent forms. All group members have a right to their viewpoints and opinions. All group members have a right to speak without being interrupted or disrespected by other group members. Group members will avoid dominating the conversation and will allow time for others to speak. The moderator has the right to guide the timing and flow of the session topics but will allow the group to determine the importance and focus of the conversation, as appropriate. Identities of group members will remain confidential. There are no right or wrong answers. Allow group members to introduce themselves with name, department, how long they have been at the organization, and something they enjoy about the organization. 1) What is it like working at [the organization]? 2) What are the factors related to your personal decision to stay at [the organization]? 3) Think back to when you were first hired. What early experiences are coming to mind? 4) What can you point to as a reason you have decided to stay? 5) How has your opinion of [the organization] changed over time? 6) How does the relationship with clients impact employees retention decisions? 7) What would you say to a new employee who is just starting out in the ID/DD industry? 8) With your own personal journey in mind, what might have better helped you along the way? 9) What did you need that you had to find yourself? 10) We are developing a Caring for the Caregiver program. What elements should we consider including? 11) Do you have a mentor or someone in the organization that you connect with? What is that relationship like? 12) What does a bad day look like at [the organization]? 144 13) What does a good day look like at [the organization]? Closing Questions/ Debrief Wrap Up & Thank You What else would you like to tell me about? Thank you very much for your time today. I appreciate hearing your insights on this topic. If anyone would like to participate in a follow up one-on-one interview or have interest in helping create content for the Caring for the Caregiver program, please remain in the room as others leave so I can capture your interest. 145 Appendix G Focus Group Protocol & Discussion Guide Stage Three Introduction, Process, Consent Ground Rules Ground rules and group norms are established to ensure mutual respect, consideration, and a supportive atmosphere for discussion. Introductions Questioning Sequence Introduce yourself. Review the studys purpose, how long you expect the focus group to take (90 minutes), and the plans for using the results. Note that the interviews will be recorded and that you will keep participants identities confidential. Distribute consent forms. All group members have a right to their viewpoints and opinions. All group members have a right to speak without being interrupted or disrespected by other group members. Group members will avoid dominating the conversation and will allow time for others to speak. The moderator has the right to guide the timing and flow of the session topics but will allow the group to determine the importance and focus of the conversation, as appropriate. Identities of group members will remain confidential. There are no right or wrong answers. Allow group members to introduce themselves with their name, department, and something they have learned during the Caring for the Caregiver program. 1) What has it been like working at [the organization]? 2) In what ways does the Caring for the Caregiver program influence elements of retention? 3) How has your opinion of [the organization] changed over the past few months? 4) How do the relationships with clients impact you? 5) With your own personal journey in mind, what has been the most helpful experience you have had at [the organization]? 6) We are evaluating the Caring for the Caregiver program. What should we know? 7) What do you like best about the program? Least? 8) Talk about your time investment. Do you feel like this program was a good use of your time and the organizations resources? 146 9) What does a bad day look like at [the organization]? 10) What does a good day look like at [the organization]? Closing Questions/ Debrief Wrap Up & Thank You What else would you like to tell me about? Thank you very much for your time today. I appreciate hearing your insights on this topic. If anyone would like to participate in a follow up one-on-one interview or feels the need to clarify anything discussed, please remain as the others are dismissed. 147 Appendix H Follow-Up Interview Consent Form Purpose You have been invited to participate in a follow-up interview as part of a doctoral research study at Marian University. The purpose of this interview is to capture your thoughts, perspectives, and experiences of being an employee at [the organization], and to provide additional information about a topic that was covered during your focus group session. The information learned in this interview will be used to develop programming for new employees at [the organization]. Procedure As part of this study, you will have a one-on-one interview via a method of your choosing, either virtually or in-person. A moderator will ask you several questions while facilitating the discussion. As approved through Marian Universitys Institutional Review Board, this semi-structured interview will be recorded, and notes will be taken. However, your responses will remain confidential, and no names will be included in the final report. You can choose whether to participate in the interview, and you may stop at any time during the study. Please note that there are no right or wrong answers to questions. Confidentiality Should you choose to participate, every effort will be made to protect your confidentiality, including using a pseudonym. A researcher will analyze the data, butas stated aboveyour responses will remain confidential, and your name will not be included in any reports. Contact If you have any questions or concerns regarding this study, please contact the Marian University Institutional Review Board at [email]. I understand this information and agree to participate fully under the conditions stated above. Signature: ________________________________________ Printed Name:_____________________________________ Date:__________________ 148 Appendix I Semi-structured Interview Protocol for Focus Group Follow-Ups Interviewee:_________________________ Interviewer:_________________________ Written Consent Collected: __________Yes __________No Introductory Protocol First let me thank you for consenting to be a part of this interview and study. The purpose of this study is to explore the experience of client-facing staff, with a focus on improving the retention of new client-facing staff. This interview will be approximately 30 minutes in length and is being held as a follow-up to the focus group that you attended. This session will be recorded. If at this time you feel you would no longer like to participate in this process, please let me know now and you may leave the call/room without judgment. Introduction Before we begin, do you have any questions for me? Now that I have confirmed consent, lets get started. Research Questions 1) Tell me about your experience at [the organization]? 2) How did your experience compare to your expectations of the focus group? 3) I wanted to follow up on [topic] that you discussed during your focus group. What else can you tell me about that? 4) After you left the focus group, was there anything else you wished you had shared or explored? 5) What suggestions can you give based on your experiences that would help improve the retention of client-facing staff? 6) Is there anything else you would like for me to know? Closing Protocol Thank you for your time, comments, and feedback. I appreciate your willingness to be a part of this study. 149 Appendix J Work and Meaning Inventory Work can mean a lot of different things to different people. The following items ask about how you see the role of work in your own life. Please honestly indicate how true each statement is for you and your work. Name: Date: Absolutely Mostly Untrue Untrue 1. I have found a meaningful career. 1 2 Neither True nor Untrue 3 2. I view my work as contributing to my personal growth. 1 2 3. My works really makes no difference to the world. 1 4. I understand how my work contributes to my lifes meaning. Mostly Absolutely True True 4 5 3 4 5 2 3 4 5 1 2 3 4 5 5. I have a good sense of what makes my job meaningful. 1 2 3 4 5 6. I know my work makes a positive difference in the world. 1 2 3 4 5 7. My work helps me better understand myself. 1 2 3 4 5 8. I have discovered work that has a satisfying purpose. 1 2 3 4 5 9. My work helps me make sense of the world around me. 1 2 3 4 5 10. The work I do serves a greater purpose. 1 2 3 4 5 (Note: While shown in print here, the survey will be converted to electronic format.) 150 Scoring instructions: Add the ratings for items 1, 4, 5, and 8 to get the Positive Meaning score. The Positive Meaning scale reflects the degree to which people find their work to hold personal meaning, significance, or purpose. Add the ratings for items 2, 7, and 9 to get the Meaning-Making through Work score. The Meaning-Making through Work score reflects the fact that work is often a source of broader meaning in life for people, helping them to make sense of their live experience. Subtract the rating for item 3 from 6 (e.g., if a client gave item 3 a rating of 2, then their converted rating would be 4 [6-2=4]); add this number to the ratings for items 6 and 10 to get the Greater Good Motivations score. The Greater Good Motivations score reflects the degree to which people see that their effort at work makes a positive contribution and benefits others or society. The Positive Meaning, Meaning-Making through Work, and Greater Good Motivations scores can all be added together to get the test-takers overall Meaningful Work score. The Meaningful Work score reflects the depth to which people experience their work as meaningful, as something they are personally invested in, and which is a source of flourishing in their lives. Low scores on any of these scales reflect an absence of work meaning, and may be predictive of poor work engagement, low commitment to ones organization and intentions to leave, low motivation, a perceived lack of support and adequate guidance from leadership or management. People who score low on these scales are also more likely to be absent from work and experience both low levels of well-being and higher levels of psychological distress. 151 Appendix K Perceived Person-Environment Fit Scale Note: All items used a 7-point scale, 1 meaning no match and 7 meaning complete match PersonJob Fit Scale (PJFS) 1. How would you describe the match between your professional skills, knowledge, and abilities and those required by the job? 2. How would you describe the match between your personality traits (e.g., extrovert vs. introvert, agreeable vs. disagreeable, and dependable vs. undependable) and those required by the job? 3. How would you describe the match between your interests (e.g., social vs. unsocial, artistic vs. inartistic, and conventional vs. unconventional) and those you desire for a job? 4. How would you describe the match between the characteristics of your current job (e.g., autonomy, importance, and skill variety) and those you desire for a job? PersonOrganization Fit Scale (POFS) POFS-Values How would you describe the match between your emphasis and your organizations emphasis on the following values? 1. honesty 2. achievement 3. fairness 4. helping others POFS-Goals How would you describe the match between your goals and your organizations goals on the following dimensions? 5. reward 6. the amount of effort expected 7. competition with other organizations PersonGroup Fit Scale (PGFS) PGFS-Values How would you describe the match between your emphasis and your group's emphasis on the following values? 152 1. honesty 2. achievement 3. fairness 4. helping others PGFS-Goals How would you describe the match between your goals and your group's goals on the following dimensions? 5. reward 6. the amount of effort expected 7. competition with other groups PGFS-Attributes How would you describe the match between you and your group members on the following characteristics? 8. personality 9. work style 10. lifestyle PersonSupervisor Fit Scale (PSFS) 1. How would you describe the match between the things you value in life and the things your supervisor values? 2. How would you describe the match between your personality and your supervisor's personality? 3. How would you describe the match between your work style and your supervisor's work style? 4. How would you describe the match between your lifestyle and your supervisor's lifestyle? 5. How would you describe the match between your supervisor's leadership style and the leadership style you desire? 153 Appendix L Organizational Approval 154 Appendix M Phase Two Script In-Person Instructions: New Employee Orientation Day Two [The organization] is partnering with a doctoral researcher to explore retention at the organization. Specifically, we are asking new employees to volunteer to participate in a program called Caring for the Caregiver. It is a program that will include additional training this afternoon and will include six peer mentoring check-in sessions with a group over the course of the next three months. You will be paid your normal hourly wage for your participation. The research will conclude with a 90-minute focus group for which you will also be paid your normal hourly wage. We are looking at why human service professionals, like yourself, choose to stay here and what supports can be implemented to make you more successful in the field. We hope to ascertain your thoughts, opinions, needs, and lived experiences relating to your role fit here and your overall job satisfaction. This is a pilot program for the organization. You are not required to participate. And if you choose to participate and change your mind later, you can step out of the program at any time without any recourse or impact on your employment. While your supervisor will know you are participating, because they will have to cover the floor for you, we will not share what you share during your sessions with your supervisor. In fact, everyone enrolled in the study will be assigned a pseudonym. Before I pass out consent forms to you to decide if you would like to participate, what questions do you have? 155 Appendix N Caring for the Caregiver New Employee Training Slide Deck 156 157 158 159 160 161  ...

... TO BE BLACK, TO BE MALE, TO TEACH: A QUALITATIVE STUDY ON THE EXPERIENCES OF BLACK MALE ELEMENTARY TEACHERS _______________________________ A Dissertation Presented to Fred S. Klipsch Educators College Department of Educational Leadership Marian University Indianapolis, Indiana _______________________________ In Partial Fulfillment of the Requirements for the Degree Doctor of Education in Organizational Leadership __________________________________ by David M. McGuire May 2023  Copyright by David M. McGuire Jr., 2023 All Rights Reserved Fred S. Klipsch Educators College Marian University Indianapolis, Indiana APPROVAL OF DISSERTATION This dissertation, To be Black, to be Male, to Teach: A Qualitative Study on the Experiences of Black Male Elementary Teachers, has been approved by the Department of Educational Leadership in partial fulfillment of the requirements for the degree of Doctor of Education. __________________________________ Dr. LaTonya Turner, Chair __________________________________ Dr. Leon Jackson, Committee Member __________________________________ Dr. Tambra Jackson, Committee Member __________________Date ii ABSTRACT Black males are underrepresented in the teaching profession at all levels, but especially at the elementary level. The low number of Black male teachers can be attributed to low salary, low regard for the profession, perception of being work for women, and lack of respect. Now more than ever after the COVID-19 pandemic and the racial unrest during the summer of 2020 the experiences of Black male teachers is important to explore. This qualitative study looked at the experiences of seven Black male elementary teachers, using Maslows Hierarchy of Needs as a theoretical framework. Through one-on-one virtual interviews seven themes emerged: physiological needs focus on salary and benefits, safety needs pertain to job security, physical safety, and emotional security, sense of belonging is often a struggle, esteem is often low, self-actualization manifests a strong desire to make a difference, COVID-19 influenced teachers experiences, and turnover and recruitment challenges for Black men in elementary education. Recommendations for future research included studying Black male teachers who spent their entire careers at the elementary level then retired. Keywords: Black, teachers, male, elementary, recruitment, retention iii DEDICATION To Jesus Christ, my Lord and Savior: Whenever I get asked the question how this process went, I always respond with the same answer, by Gods grace. I have grown so much both personally and professionally through this dissertation process. The one thing I can say is that because of you, I am better, wiser, and have a deeper appreciation for the process. Thank you, God, for this opportunity and thank you for allowing me to make it to the end. What, then, shall we say in response to these things? If God is for us, who can be against us. Romans 8:31. To my daughter, Zuri Reign: You are my forever blessing. I know I must have done good for God to bless me with you. I hope when you get older, you will understand what your Dad has accomplished. Everything I do is to provide a better life for you. I hope you grow up and be as proud to be my daughter as I am proud to be your Dad. To my parents, David, and Veronda McGuire: I truly believe I am a good person because I was created from the love of you two. I do not get a chance often to publicly thank you for all you have done for me. Allow this to be a permanent and published example of my appreciation and love for all you have done for me. My goal every day is to make you proud of the man I have been become. I hope you are proud. You raised a Dr! To my siblings, Justin, and Emily: Everything I have done as your big brother is to set a path and foundation for you all to follow. While I do not say it often, you are my motivation and inspiration and I hope that you are proud to have me as your big brother. I love you! iv ACKNOWLEDGEMENTS Thank you goes out to: My Committee for pushing me and challenging me early in the process. I am so appreciative for the proposal defense and the feedback you provided. I hope you are just as proud to be on my committee as I am for each of you as committee members. Cohort 1 for our journey that began in the middle of a pandemic, for the deep and personal conversations we had in class, and for each of us being the trailblazers of a new program. It has been an honor to learn beside you these last three years. The Participants for lending your voice, being vulnerable, and the strength you all show both in and out of the classroom. Black Male Teachers Past, Present, and Future for leading the way, for blazing a new path, and for picking up the baton and taking it to new heights. I pray that our light continues to shine for many years to come. v TABLE OF CONTENTS CHAPTER PAGE LIST OF TABLES ..................................................................................................... viii LIST OF FIGURES ..................................................................................................... ix CHAPTER 1: INTRODUCTION ................................................................................. 1 Personal Story ......................................................................................................... 2 Statement of the Problem ........................................................................................ 8 From Brown to COVID-19 ......................................................................... 9 Brown Impact on Black Teachers ............................................................... 9 COVID-19 Impact on Black Teachers ...................................................... 11 Purpose of the Study ............................................................................................. 15 Significance of the Study ...................................................................................... 16 Theoretical Framework ......................................................................................... 17 Maslows Hierarchy of Needs .................................................................. 17 Research Questions ............................................................................................... 18 Delimitations and Limitations............................................................................... 19 Definition of Key Terms ....................................................................................... 20 Summary ............................................................................................................... 21 CHAPTER 2: REVIEW OF RELEVANT LITERATURE ....................................... 22 Introduction ........................................................................................................... 22 Theoretical Framework ......................................................................................... 23 Black Male Teachers as Role Models ................................................................... 24 Black Male Teachers as Disciplinarians ............................................................... 26 Black Male Teachers as Surrogate Fathers ........................................................... 28 Black Male Teachers as Symbols of Diversity ..................................................... 29 Black Male Teachers as Academic Influencers .................................................... 31 Black Male Teachers as Change Agents ............................................................... 33 Black Male Teachers as Tokens ........................................................................... 34 Gender Norms at the Elementary Level................................................................ 36 Perceptions of Black Male Elementary Teachers ................................................. 38 African American Males Path to Teaching ......................................................... 39 The Role of HBCUs in Training African American Male Teachers .................... 42 Teaching Programs That Support African American Males................................. 45 Teach for America .................................................................................... 46 Call Me MISTER ...................................................................................... 47 Summary ............................................................................................................... 48 CHAPTER 3: METHODOLOGY .............................................................................. 50 Introduction ........................................................................................................... 50 Connection Between the Theory and Research .................................................... 50 vi Research Questions ............................................................................................... 51 Qualitative Methodology ...................................................................................... 51 Participants............................................................................................................ 52 Selection of Participants ........................................................................... 53 Number of Participants ............................................................................. 54 Recruitment of Participants....................................................................... 54 Background of Participants ....................................................................... 54 Data Collection ..................................................................................................... 57 Data Analysis ........................................................................................................ 58 Trustworthiness and Credibility............................................................................ 60 Role of the Researcher .......................................................................................... 61 Member Checking................................................................................................. 62 Summary ............................................................................................................... 62 CHAPTER 4: RESULTS ............................................................................................ 64 Introduction ........................................................................................................... 64 Participant Descriptions ........................................................................................ 65 Wes ........................................................................................................... 65 Horace ....................................................................................................... 66 Eugene....................................................................................................... 66 Ralph ......................................................................................................... 67 Augusta ..................................................................................................... 67 Herman...................................................................................................... 68 Julian ......................................................................................................... 68 Data Analysis ........................................................................................................ 69 Results of the Analysis.......................................................................................... 76 Physiological Needs Focus on Salary and Benefits .................................. 76 Safety Needs Pertain to Job Security, Physical Safety, and Emotional Security ..................................................................................................... 76 Sense of Belonging is Often a Struggle .................................................... 78 Esteem is Often Low ................................................................................. 80 Self-Actualization Manifests as a Strong Desire to Make a Difference ... 83 COVID-19 Influenced Teachers Experiences ......................................... 83 Turnover and Recruitment Challenges for Black Men in Elementary Education .................................................................................................. 84 Summary ............................................................................................................... 86 CHAPTER 5: DISCUSSION OF RESULTS AND IMPLICATIONS ...................... 89 Introduction ........................................................................................................... 89 Summary of Major Findings ................................................................................. 90 Research Question 1 ................................................................................. 90 Research Question 2 ................................................................................. 91 Research Question 3 ................................................................................. 91 Research Question 4 ................................................................................. 91 vii Research Question 5 ................................................................................. 92 Research Question 6 ................................................................................. 92 Difference in Participants Background ..................................................... 93 Implications........................................................................................................... 95 Recommendations ................................................................................................. 96 Conclusion ............................................................................................................ 98 Final Remarks ....................................................................................................... 99 REFERENCES ......................................................................................................... 100 APPENDIX A RECRUITMENT EMAIL ................................................................ 122 APPENDIX B RECRUITMENT FLYER ................................................................ 124 APPENDIX C RECRUITMENT NOTE .................................................................. 125 APPENDIX D PARTICIPANT RECRUITMENT SURVEY ................................. 126 APPENDIX E CONSENT EMAIL TO POTENTIAL PARTICIPANTS................ 127 APPENDIX F DEMOGRAPHIC QUESTIONNAIRE ............................................ 129 APPENDIX G RESEARCH AND INTERVIEW QUESTIONS ............................. 130 APPENDIX H INTERVIEW PROTOCOL SCRIPT ............................................... 132 APPENDIX I IRB APPROVAL............................................................................... 136 viii LIST OF TABLES TABLE PAGE 1 Participant Descriptions .................................................................................. 67 2 Open Coding Examples ................................................................................... 68 3 Code Frequency ............................................................................................... 69 4 Themes/Subthemes/Codes ............................................................................... 71 ix LIST OF FIGURES FIGURE 1 PAGE Thematic Map .................................................................................................. 73 1 CHAPTER ONE INTRODUCTION To be Black and conscious in America is to be in a constant state of rage. James Baldwin There are those who ask whether the United States wants an educated Black man teaching the children. Thinking back, Black men who taught were killed. Dr. Martin Luther King, Jr. was killed, Malcolm X was killed, Medgar Evers was killed, and Fred Hampton was killed. Far too often, history has shown us that when individuals from marginalized groups seek to have their voice heard, those in power work to silence them. History has also shown that the best way to destroy the Black community is to go after its men (Smiley & Fakunle, 2016). Black men are often theorized as defective (Curry, 2017). They have been marginalized theoretically and compared to a norm by which they are usually judged to be lacking (Saint-Aubin, 1994). Royster (2007) describes the price Black men pay for enacting masculinity. In a study comparing the trajectory of less affluent Black men and white men Royster (2007) concluded the masculinity of Black men impacted their interactions with the education market, the labor market, and the criminal justice system. Black men alone cannot change the landscape of teaching; however they are important to the improvement (House, 2017). Black men have and will continue to be a force within our nations education system, but our nation must come to truly appreciate their value in the classroom (House, 2017). Often the media in our nation pushes a narrative that teaching is the worse career and that teachers are rushing to leave the profession (Olmstead, 2021). 2 The teaching profession was one of the first in which women were allowed to practice and by many standards today, teaching is considered a profession dominated by women (Perry, 2021). There are not enough African American male teachers (Graham & Erwin, 2011). While there are more Black women teachers, the numbers of Black men teachers are fewer (Schaeffer, 2021). Today, it is critical to achieve a diverse and inclusive workforce within K12 education. Black male teachers positively impact all students, and the affects they can have on students of color cannot be understated. Causey (2017) cites a 2017 study by researchers from John Hopkins University, having at least one Black teacher in elementary school cuts the high school dropout rate by 39% and raises the college aspirations for both boys and girls by 19%. Black students tend to respond better when those leading the classroom look like them. This study examined the topic of Black male teachers, specifically in relation to teaching in elementary schools. Personal Story The impulse to dream was slowly beaten out of me by experience. Now it surged up again, and I hungered for books, new ways of looking and seeing. Richard Wright Unlike many of the students with whom I have had the opportunity to work, both parents raised me in the same household. This was a privilege that I never fully understood until I got older. Neither my mom nor my dad attended college after high school, but, for me, going to college was not much of a choice for as far back as I can remember. While I did not learn the importance of college from my parents, they taught 3 me many other valuable lessons. My parents were my first and ultimately best teachers. The lessons I learned at home have impacted me long after my traditional education experience. My dad taught me the importance of hard work and being a man. I aspire to be the father to my daughter that my father was to my siblings and me. My mother showed me what it means to love and what it means to sacrifice for those you love. My parents wanted me to attend college and made sure that my K12 education experience was the best. My education journey began at the age of five, when a drive to visit my Kindergarten school was shifted by tears and what my mother saw. As my parents visited the school that I was set to attend in the Fall, my mother became overwhelmed with tears in fear that the school I was going to attend was not what she wanted. The location of the school, the surrounding area, was not what she envisioned for her first-born son. So, she did what she felt was right. She used my grandmothers address and lied to put me in a school in a different neighborhood. It is amazing how one decision puts you on a path that will shape your life for years to come. I spent grades Kindergarten through fifth grade using my grandmothers address until my parents moved to the district where I had been attending. The experience of attending a school outside my neighborhood shaped my present work because it showed me that no parent should have to lie about their address or drive their child across town to attend a quality school. Every family should have access to a high-quality school that they would be proud to send their child to. My teaching journey began at the age of 17, specifically while sitting in a math classroom in my junior year of high school. I became more aware of the underrepresentation of males in teaching, and specifically Black males. In elementary school, I 4 had two male teachers, and both were White. I had one male teacher in middle school, my first and only African American male teacher in seventh grade. At the time, there were only two in the entire building. In high school, I had zero. In high school, I also noticed the difference in how Black boys and other students were treated. Could it be due to the lack of representation? Imagine being in a space where there is barely anyone who looks like you. I did not have a Black male classroom teacher in high school, but I did grow closer to my middle school basketball coach, Mr. Bryant (pseudonym). He was the social studies teacher, but he founded an organization called Young Men of Purpose. My engagement with the Young Men of Purpose program in high school was my first experience mentoring younger students, and it fed my hunger to be a teacher. While I never had Mr. Bryant as a classroom teacher, he was an important role model of the type of Black male teacher I aspired to become one day. My senior year of high school, while a great time in my life, as one major chapter was closing and an important chapter was beginning, was also a time when I had more questions than answers. I knew the next chapter of my life was about finding answers to the questions. The one question that I did not need to find an answer for was what I wanted to do with the rest of my life. After high school, I attended Central State University, a Historically Black College and University (HBCU) in Wilberforce, Ohio. My experience at Central State University was one of the best experiences of my life. My experience there reinforced and shaped the type of educator I would eventually become. I majored in English, with a focus on African American literature. My first year, I met someone who guided me through the next 4 years. Nella Hurston (pseudonym) was my freshman English teacher and also my boss for my work-study job at the Hallie Q. Brown Memorial Library. It was 5 there when Professor Bailey introduced me to the author and book that forever changed my life: The Fire Next Time, by James Baldwin. Reading The Fire Next Time and other works by Baldwin opened my eyes to how the racial injustice Baldwin wrote about during his time was still prevalent some 40 years later. Baldwin and other works by African American writers inspired me as an educator but inspired me, more importantly, as a Black man in the United States. During my junior year, I had the opportunity to join Alpha Phi Alpha Fraternity, Inc., the oldest of the Divine Nine Black Greek letter organizations. Our fraternitys aims were the following: Manly Deeds, which meant uplifting each other as we climb and not tearing one another down; Scholarship, which meant growth in knowing oneself and developing into a more well-rounded person; and Love for all Mankind, which meant to love everyone regardless of their pasts. I was fortunate during my 4 years at Central State University to learn so much that helped shaped me into the educator I became both as a teaching practitioner and, importantly, as Black man. My career began the fall after graduating. I returned to my alma mater and taught English in the alternative program for students who had been removed from the general education setting. It was a great experience, both as a chance to get my feet wet in the profession, but also because it pushed me and challenged me, as the students had been pushed aside and the program, I was teaching in became their second chance at moving back into the general education space. The program was great and, unlike in my own K 12 experience, the other two teachers in the program were Black males. So, these students had an experience that I did not have by being taught by Black males. During 6 my first few years, I also had the opportunity to coach track and field, which I truly enjoyed, and I continued to build my skills as an educator and teacher. After 2 years, I left the traditional school setting and worked for a non-profit focused on introducing students to a career in healthcare. While I was no longer in schools teaching, I had the opportunity to travel to different schools across the city and to talk with students about careers in healthcare. While visiting those schools, I was amazed how some high school kids had the same experiences as me even six to seven years after I had graduated. The students, who were predominately of color and mostly African American, lacked the representation of African American male teachers. I saw plenty of Black women teachers, but not many males. When these schools did have African American males in the building, they were not classroom teachers. They served as instructional assistants, coaches, behavioral specialists, and in-school suspension coordinators. I learned, traveling to those schools, that Black males were being pigeonholed into roles in schools that were disciplinary rather than instructional roles. After doing that work for 2 years and seeing the landscape of the schools, I decided to return to the K12 space. This time, I entered a charter school. I taught high school English at a former Indianapolis Public School (IPS) high school that the state had taken over and converted into a charter school, which was now run by a charter management company. My 2 years there molded me into a better teacher and introduced me to the idea of leadership within a school. During that school year, I began studying to receive my building administrators license through a program at Marian University. As I was older and had some previous teaching experience, many of the new teachers and others in the building leaned on me. It was a tough situation, but one that I was used to 7 considering my experiences in the alternative program. While there, I received a call from Mr. Bryant (pseudonym) who was the principal of a new middle school program back in Pike Township. He asked if I had any interest in returning. Intrigued by the opportunity of middle school, I left and returned to Pike. The next year catapulted me and the rest of my career. In July of 2015, I was returning to Pike, but I had some other interest in education. I began to write and help start a blog focused on education stories in Indianapolis. I was beginning a policy fellowship through Teach Plus and was advocating for education policy. My focus was the lack of teacher diversity and the recruitment and retention of African American male teachers. I also helped launched a program called the Educate ME Foundation, which focused on trying to increase the number of Black male teachers in schools. The entire year and the work I was doing prepared me for the summer of 2016, when I was given an opportunity that ultimately changed my life. After my second round at Pike ended after a year, I received my first principalship at a middle school in our charter network. Then, the next year, I was moved to the elementary school. Excited about the challenge, I flashed back to the 17-year-old version of me, when I had watched the African American boys in my school struggle academically, behaviorally, and socially. I then looked at the teaching staff and saw that they did not have teachers who looked like them. The difference now is that I was ten years older and two degrees wiser, and I could do something about it. The motivation for this dissertation began as I worked to increase the number of African American male teachers in my building and realized that, while there are some out there, there are not many who are interested in elementary school. 8 Statement of the Problem Im always trying to fight on both fronts and not act like schools can change everything but also not act like schools cant change things. Howard Fuller The recruitment of teachers both at the primary and secondary levels of education has become a major challenge for many school leaders (Hanson, 2005). There are benefits for Black students to have at least one Black teacher, especially in elementary and middle school. Elementary and secondary teachers in the United States are approximately 86% White, although racial and ethnic diversity in public school students has increased over time (Egalite et al., 2015). Research shows that having a teacher of the same race and ethnicity can have a positive impact on student motivation, achievement, and attitude in school. By having a BIPOC teacher rather than a non-BIPOC teacher, the expectation level for minority students increases (Egalite & Kisida, 2018). In Indiana, the low numbers of Black male teachers are alarming. Minor (2022) states that according to the Indiana Department of Education (2022), 3,173 of the 75,174 teachers in Indiana are Black. Out of those who are Black, only 888 are males. In other words, just 1.2% of teachers in Indiana are Black males (Indiana Department of Education 2022). Black male teachers were displaced at a higher rate than Black female teachers between 1954 and 1968 (Fenwick, 2022). In the decade after the Brown v. Board of Education (1954) decision, that number dropped by half (Tillman, 2004). Almost 40,000 Black teachers and principals lost their jobs because the court decision shut down the predominantly Black schools. In her book Jim Crows Pink Slip, Leslie Fenwick 9 highlights how despite possessing qualifications that exceed their white counterparts, Black principals and teachers were illegally demoted, dismissed, and fired because of the resistance to Brown v. Board (Fenwick, 2022). Black teachers taught Black students in Black schools before Brown v. Board of Education (Tillman, 2004). After the verdict, things quickly changed, and the image of Black males as teachers in schools was almost wiped away. When schools were integrated, many Black educators lost their jobs due to the white resistance of Brown v. Board (Fenwick, 2022). From Brown to COVID-19 Jim Crows Pink Slip was about telling stories, to challenge the quaint notion about Black educators of an era. Dr. Leslie Fenwick Brown Impact on Black Teachers In 1896, the court ruling in Plessy v. Ferguson upheld a Louisiana state law that allowed for equal but separate accommodations for the whites and colored races. Almost 60 years later, a new argument was bought to the Supreme Court that rejected the separate but equal clause in Plessy v. Ferguson as it related to public education, while also implying that it was unconstitutional in all other aspects of public life. Many Black students were the beneficiaries of the Brown v. The Board of Education (1952) Supreme Court decision. It asked, does the segregation of children in public schools solely on the basis of race deprive the children of the minority group of equal education opportunities? (McCullough, 2012). After the courts ruling in Brown v. Board of Education, African American schools disappeared, and Black students were 10 integrated into predominately White schools. However, many White parents refused to allow their children to be taught by Black teachers (Dougherty, 1998). Many argue that Brown v. Board of Education is one of the most significant milestones of the Civil Rights Movement, and there is no denying the impact it had on the Black teaching force in this country. It paved the way for all-Black schools where Black children could thrive and received a quality education from Black teachers. How can a court ruling give children so much, yet take so much at the same time? While many Black children now had equal access and opportunity to attend high quality schools, they no longer had Black teachers as role models. They lost the individuals who uniquely understood their backgrounds. In many instances, the Black voice was silenced in public education in this country. Despite the lack of opportunities for Blacks, one career path available to Black communities was in teaching. Oakley et al. (2009) stated that over 38,000 Black teachers in the South and other border states lost their jobs after the Brown v. Board of Education ruling. According to Leslie Fenwick from Howard University, prior to Brown there were 17 states that had segregated school systems, and 35% to 50% of the teaching force was Black (Will, 2019). The impact of losing of so many Black teachers is still impacting the teaching force today. In 2000, the percentage of teachers of color in the United States was 14% (Oakley et al., 2009). There are no states in the United States that produce a Black teaching force that high. While a Civil Rights victory, Brown v. Board of Education had unintended consequences. There was no way to predict how it would impact the Black teaching 11 force, but the case and the white resistance caused the dismissal, demotion, or forced resignation of many highly qualified and experienced Black teachers (Will, 2019). COVID-19 Impact on Black Teachers In March of 2020, schools changed drastically as COVID-19 cases began to increase worldwide. School closures were not new; schools had closed before due to natural disasters, such as tornadoes and hurricanes. For instance, Hurricanes Katrina and Rita caused roughly 700 schools to close for months, and some never reopened in 2005 (Sacerdote, 2008). During COVID-19, the first school closure was on March 12, when Ohio became the first to close schools statewide (Camera, 2020). On March 19, Indiana followed suit (Herron, 2020). By late March 2020, all U.S. public school buildings were closed as recommended by the U.S. Centers for Disease Control and Prevention (Education Week, 2020). The general belief was that schools would be closed for only a few weeks, but, by May, almost all states had closed their doors for the remainder of the 20192020 school year (Education Week, 2020). While the COVID-19 school closures drastically impacted students, specifically students of color, it also took a heavy toll on teachers. In a survey by Education Week (2021) in April 2020, about 56% of teachers said that their morale level was low. Many believed that the 20202021 school year would bring a sense of normalcy, but it only brought new challenges as many schools opened remotely. Teachers had to learn a new method of teaching and interacting with their students. The shift caused teacher burnout and ultimately led to many leaving the profession (Education Week, 2020). The biggest harm of COVID-19 was on the recruitment of teachers; it was already hard enough to recruit Black men to become teachers, but COVID-19 and the uncertainty 12 how teaching and school would look in the future made it even more difficult. Teaching is a demanding job in normal circumstances, due to the challenges of classroom management, lack of resources, heavy workload, and the pressures of standardized tests. With a major health crisis and a switch to a new form of teaching, it became even harder. For Black teachers, this is even more challenging due to lack of diversity in schools and the pressure to perform above and beyond just to keep their jobs. The COVID-19 pandemic required teachers to switch to remote instruction, all while the pandemic disproportionally killed people of color. Many students, especially Black students, did not have reliable internet at home to log on to class. Plenty of studies show that remote learning did not work for students of color, but it was also hard on Black teachers. Studies reported that Black teachers were more than twice as likely as other teachers to leave their jobs by the end of the 20202021 school year (Steiner & Woo, 2021). COVID-19 hurt the recruitment of aspiring Black male teachers. The pandemic impacted higher education budgets, and budget cuts caused many Black students to leave or delay the completion of their programs. The cuts universities made ultimately led to smaller financial aid packages for students, and this impacted Black students who tend to rely more heavily on those packages to complete school. Black students enrolled in teacher preparation programs are also more likely to rely on federal student loans as compared to White students (Fiddiman et al., 2019). During the early part of the COVID19 pandemic, fewer students applied for the Free Application for Federal Student Aid (FAFSA), which is needed to get financial aid. The result was a dip in college enrollment and enrollment and teacher preparation programs. 13 Black male students like many other students who were aspiring to become teachers were impacted by interruptions to their student teaching and other practicum field experience due to COVID-19 (VanLone et al., 2022). Many of the teachers entering classrooms during the 20212022 school year did not have a normal student teaching experience. They found themselves doing student teaching online or not at all. Now, many are entering the profession with little to no classroom experience and are expected to students who are behind academically. Field experience influences the success of teachers, allowing them to feel more comfortable and to have mentors to help them navigate their first few years. The COVID-19 pandemic has exposed and worsened the long-standing societal disparities impacting Black men in our country. The intersection between the COVID-19 pandemic and the social unrest that unfolded in the wake of the killing of George Floyd and others has significantly impacted Black men. Black men face a unique challenge as they grapple with the health risks of COVID-19 and the social unrest that erupted. The pandemic disproportionately affected Black communities, with higher infection rates and more severe outcomes, including higher mortality rates. The pandemic disproportionately affected Black communities, with higher infection rates and worse health outcomes, including higher mortality rates among Black individuals (APM Research Lab, 2021). Black men, in particular, faced elevated risks due to their overrepresentation in essential frontline jobs that exposed them to the virus (Hawkins & Stevenson, 2020). Simultaneously, the social unrest triggered by the deaths of Black individuals continued to highlight systemic racism and police brutality, igniting a nationwide movement. Black men were at the forefront of protests and advocacy efforts, leading to a 14 complex dynamic where they were simultaneously at greater risk of contracting COVID19 and subject to increased scrutiny and potential violence during protests (National Bureau of Economic Research, 2020). However, they also faced heightened scrutiny, police brutality, and arrests during these protests, underscoring the risks they took to demand change. The economic fallout from the pandemic, including job losses and economic insecurity, disproportionately affected Black men, exposing existing disparities in income and employment opportunities (Bureau of Labor Statistics, 2021). Both the COVID-19 pandemic and the social unrest significantly impacted Black male teachers, shedding light on the resilience and vulnerabilities of these teachers. As teachers, Black males have played a crucial role in the lives of their students, serving as mentors and role models. However, the pandemic forced a sudden shift to remote learning, challenging teachers. The experiences of Black male teachers during the COVID-19 pandemic and social unrest highlight the need for greater support and recognition for their contributions. Policymakers and education leaders should consider the unique challenges they face, including the digital divide, increased emotional labor, and job insecurity, and work to address these issues through targeted initiatives and policies. Additionally, efforts to diversify the teaching profession should be at the forefront to ensure that Black male teachers voices and perspectives continue to enrich their students' lives and contribute to the broader discourse on racial equality in education. Teacher shortages were already a growing problem in the United States before the COVID-19 pandemic, particularly in high poverty schools where many Black male 15 teachers work (Garcia and Weiss, 2019). The shortage worsened as many schools closed due to not being able to fill vacant teaching positions. Other schools remained opened but struggled with the large number of teacher vacancies, leaving those teachers who remained to be overworked. As school struggled to keep up with the COVID-19 safety protocols, many teachers were making a choice between their jobs and their health. School districts have had to be creative in how they recruit and retain teachers of color, specifically Black men (Thomas, 2018). Purpose of the Study Education is an important element in the struggle for human rights. It is the means to help our children and thereby increase self-respect. Malcolm X The purpose of this study was to examine why Black males decide to teach at the elementary level. There has been research done to highlight the views and the perceptions of Black males who teach at the elementary level (Bristol, 2014; Walker, 2012; Holmes, 2021). These researchers focused on recruitment and retention strategies. Additional perspectives on research has been conducted to approach the recruitment and retention of Black male teachers in looking at social identity and mentorship (Opoku, 2022). The purpose of this research was to understand why Black males teach at the elementary level. This research will address recruitment and retention, but from a different perspective than what has previously been done. Examining the why of these Black male elementary teachers and the different levels of needs for Black male elementary teachers will provide a better understanding and ultimate aid in the recruitment and retention. 16 Significance of the Study Education remains one of the Black communitys most enduring values. It is sustained by the belief that freedom and education go hand in hand, that learning, and training are essential to economic quality and independence. Marian Wright Edelman Research in the education field makes a compelling case for the benefits of a diverse teaching force. While minority students would be the greatest beneficiaries of a diverse teaching force, there is evidence that all students would benefit, along with the country at large (Shanker, 2015). McCall (2017) studied the experiences of Black male teachers who left the profession using the framework of Maslows Hierarchy of Needs. An advancement of that study was to focus on elementary teacher and teachers who stayed in the profession using the same framework. This study provided additional insight on the topic. The significance of this study was to provide insight on the lived experience of Black elementary teachers on why they pursued the profession, how they describe success, barriers they faced, how they view their importance, and what they believe helps recruit more Black male teachers to the profession. This research benefits African American males who desire to become teachers, particularly at the elementary level, by offering them valuable insight from current Black male elementary teachers. This study is significant in elevating the voice of Black male teachers, particularly at the elementary level. The majority of elementary-level teachers are women, and males, particularly Black males, are almost absent (Young and Young 2020). An additional significance is added to this study, when factoring in how the COVID-19 pandemic impacted the lived experiences of these teachers. COVID-19 added 17 additional stressors for teachers with the original shut down of schools and the move to virtual learning. The ever-changing guidelines for safety, social distancing, the back and forth quarantining all added to an already difficult job. Pressley (2021) says that teachers are facing new demands and showing high levels of stress with the new instructional requirements and the anxieties due to the current state of the education profession and the pandemic. This study became even more significant and will add an important contribution by exploring Black male elementary teachers who in some way had their experience impacted by COVID-19. Theoretical Framework The purpose of education is to create in a person the ability to look at the world for himself, to make his own decisions. James Baldwin Theoretical frameworks provide four dimensions of insight in qualitative studies. They provide focus and organize the study, expose, and obstruct meaning, connect a study to the existing scholarship and terms, and identify its strengths and weakness (Collins & Stockton, 2018). Maslows Hierarchy of Needs (1943) will be the theory utilized in this study. The theory will aid in the topic development, the literature review, and the studys research design. Maslows Hierarchy of Needs While considering the motivation of Black male teachers to choose the elementary level, this study used Maslows Hierarchy of Needs (1954) in examining and understanding motivational. Maslow (1943) states peoples primary aim is to meet their basic needs, while also aiming to meet higher needs. This remains until they can reach 18 the highest of need of all, self-actualization. Maslow (1970) defined self-actualization as reaching the fulfillment of ones potential in life, along with developing an appreciation for life and growth in ones skills. Maslow (1962) determined there are five levels. The levels are as follows: physiological, safety, belongingness, self-esteem, and selfactualization. Before a person can find complete satisfaction and act unselfishly all five levels must be satisfied (McCall, 2017). Deep love and belonging happens with the physiological and security needs are met reasonably (Maslow, 1962). McCall (2017) cited Maslows (1962) suggestion that when self-esteem needs are reasonably met, a person can begin to seek opportunities for achievement and advancement through a mastery given task. McCall (2017) concluded in a study that making a difference was important in the beginning, but the lack of return became a priority need for the participants. Research Questions Education must enable a man to become efficient, to achieve with increasing facility the legitimate goals of his life. Dr. Martin Luther King Jr. While considering the impact of COVID-19 and in what ways did it impact the Black male teachers at the elementary level, this study considered the following overarching question: What were the lived experiences of Black male teachers that contribute to their motivation to teach at the elementary level? Using Maslows Hierarchy of Need the following research questions guide this study: Research Questions: RQ1: What physiological needs are met for the Black male teacher? 19 RQ2: What safety needs are met for the Black male teacher? RQ3: How does the Black male teacher feel a since of belonging? RQ4: What self-esteem needs are met for the Black male teacher? RQ5: What self-actualization needs are met for the Black male teacher? RQ6: How did the Black male experience COVID-19 as an elementary teacher? Delimitations and Limitations The study had both delimitations and limitations. Delimitations are defined as the scope of the study or established parameters. Limitations are the constraints on the study based on the research methodology and design (Miles, 2019). Delimitations are selfimposed restrictions to the study, while limitations are restrictions inherent to the methodology (Miles, 2019). The researcher can control for the delimitations in the study (Miles, 2019). One delimitation is that the study focused only on male teachers. The choice to focus on this group limited the researchers ability to include results from other genders of teachers. A second delimitation of the study is that focused only on Black teachers. The choice to focus on this group limited its ability to include results from other races of teachers. A third delimitation of the study is that it focused on Black male teachers from the elementary grade level. This limited the studys ability to include results beyond this grade level. One limitation of the study was whether the participants are being honest in their responses to the question and honest about their experiences as Black male elementary teachers. A second limitation was whether the participants will be available for the 20 allotted time to conduct the interviews or focus groups. A third limitation was in capturing the complete experience of each participate. A fourth limitation was the participate varied in age, grade levels taught, school types, and years of experience. A fifth limitation was sample size that is smaller than the total population. Definition of Key Terms In education, terms can have multiple meanings. This section provides definitions and explanations of key terms in this study. African American male: This term refers to those who identify as African American and who come from African descent. African American and Black are used interchangeable through this study. Catholic school: A Roman Catholic parish-based, elementary school (Jordan, 2016). Charter school: A public school that operates under contract, or charter, entered between the schools organizer and a charter school authorizer, sometimes referred to as a charter school sponsor (Indiana Charter School Board, 2021). Diversity (teacher): In this study, diversity is used as the range of identities that exists in a group of teachers. Elementary school: Schools that serve grades Kindergarten through Grade 6. Elementary teacher: Teachers who teach grades Kindergarten through Grade 6. Pigeon-holed: This refers to African American teachers who are forced into positions in schools, but not as classroom teachers. Private school: A school that is established, supported, and run by a nongovernmental agency. 21 Teacher recruitment: An effort to increase the number of qualified teachers who accept a teaching position in a school. Teacher retention: The ability to keep teachers at a school year after year. Traditional public school: A school that provides an educational service and receives public funds as the primary support and is operated by a district, metropolitan, local, or state educational agency. Traditionally trained: Teaching preparation that happens during a 4-year collegiate program of study for a Bachelors degree. Transition-to-teaching program: Post-BA teacher preparation Under-represented: Teachers from a group that has been historically underrepresented in a school, such as males and African American males. Summary Education and work are the levers to uplift a people. W. E. B. Du Bois This chapter highlighted the need for the study. The purpose of this qualitative design study was to explore the experience of seven Black men teaching in elementary schools. The motivation for the research was two-fold: the researchers experience as an elementary principal in recruiting Black male teachers, and the overall disproportionately number of Black male teachers in elementary schools across the country. The study used a phenomenological design to discover Black male elementary teachers motivations and their path to teaching in elementary schools. The researcher collected data through individual interviews, panel discussions, and focus groups. Chapter 2 of this study contained a review of the literature related to this study. 22 CHAPTER TWO LITERATURE REVIEW Introduction As described in Chapter 1, there is a growing need in U.S. schools to recruit and retain Black male teachers. The National Center for Educational Statistics (NCES, 2021) reported that during the 20172018 school year, there were 3.3 million teachers. White women comprised about 76% of the teaching force. Teachers in the United States have been a topic of concern and the federal government has made efforts to increase diversity in the teaching profession by focusing on changes to student demographics, the advantages of a diverse teaching force, and the turnover rate of teachers of color (Sun et al., 2018). The need for Black male teachers is due to the disproportionately high number of White woman teachers. Many schools across the country are growing in diversity. The number of minority students is increasing, especially the number of Black students. While the majority of students in urban areas are Black, most teachers in urban schools are White (Brockenbrough, 2014). The diversity of the teacher force has lagged for years and needs to catch up. Despite long-term career opportunities in teaching, there is still a shortage of Black male teachers. Mitchell (2016) stated that despite the efforts from researchers, policymakers, and alternative teaching pathways, the Black male is still underrepresented in the classroom. This chapter highlights literature on the importance of Black male teachers, specifically at the elementary level. The literature review begins with a description of Maslows (1954) hierarchy of needs. The current study focused on the many roles Black male teachers play within schools, including role model, disciplinarian, surrogate father, 23 symbol of diversity, academic influencer, change agent, and token. Previous researchers have explored the paths many Black male teachers take on their way to the classroom. These paths include both traditional routes through programs like Call ME MISTER and non-traditional routes such as Teach for America. The chapter concludes with an examination of gender norms at the elementary level, Black men in the elementary grades, and the perceptions of Black male elementary teachers. Theoretical Framework Maslows (1954) hierarchy of needs provided the framework for this qualitative study. Maslow created this theory of basic, psychological, and self-fulfillment needs that motivate people to move consciously or subconsciously through levels or tiers based on inner and outer satisfaction of those needs. Walker (2017) referenced Maslows theory in his study to lay a foundation that focused on motivation. Walker stated that motivation was a contributing factor to the satisfaction of an individual. In Walkers study, there were some similarities in participants perspectives of the attrition and retention of Black males. Three main themes emerged from the study, including (a) role model, (b) recruiting, and (c) financial aspect (Walker, 2017). Walkers participants found motivation in one or all these of these themes. Walker concluded that the participants were motivated for the children to serve as role models, because of the low number of Black male elementary teachers. Money and work-related issues were dominant themes for many of the participants in Walkers study. McCall (2017) conducted a study to understand why Black males left the profession, using Maslows (1954) theory as a framework. McCall concluded that while Black men entered the profession to make a difference and impact the children they 24 taught, the low return on investment diminished the appeal of the profession. The participants mentioned low salaries and said benefits were important for Black male teachers (McCall, 2017). The low salary did not meet the physiological needs of the participants, which is why they left. Another common theme among participants in McCalls study was their sense of belonging. Many of the participants mentioned the challenges they faced while working in a female-dominated workplace. They were careful of their verbal communication, body language, and relationship acquaintances (McCall, 2017). These studies by McCall and Walker (2017) highlighted the utility of Maslows theory in understanding why Black males stay in and leave positions as elementary school teachers. Black Male Teachers as Role Models Black male teachers are often viewed as role models for students. Holland (1991) argued for increasing the number of Black male teachers so that Black boys may have more role models. There is a growing call for Black male teachers to help combat the plight that many Black male students face in urban schools (Rezai-Rashti & Martino, 2010). Rezai-Rashti and Martino (2010) stated that while Black male teachers described the pressure and self-regulation that accompanied being role models and teachers, they also believed they were given opportunities to disrupt stereotypes. Research suggests that Black boys are more influenced by Black male teachers (Warren, 2017) During his 2011 commencement speech at Morehouse College, then Secretary of Education, Arne Duncan, launched a teacher recruitment campaign called Black Men to the Blackboard. During the address, Secretary Duncan said, Less than three percent of the nations teachers are person of color during a time when Black children need Black 25 teachers as mentors and role models (Bristol, 2014, p. 24). Tafari (2018) agreed, as she believed one of the best ways to rectify the crisis affecting Black boys in schools was to ensure they were immersed in an educational environment where they could have realistic role models who shared their cultural experiences and had similar cultural capital. This research did not just argue that Black male teachers at the elementary level were role models, but also highlighted how their presence as role models for Black students could change students perceptions as they matured. Black male teachers as mentors can support students in developing conflict resolution skills and strategies (Young & Young, 2020). If more students interacted with Black male teachers earlier on, negative stereotypes about Black men may be challenged. Additionally, it would allow Black youth who lacked father figures to see Black men working in other professions, beside sports and entertainment. Black male teachers as role models can support children of color, especially the educational, social, and cultural needs of Black boys (Jones, 2006). Chmelynski (2005) noted that students of color needed teachers of color to help them develop those skills. Black students may better identify with Black male teachers as role models because of their shared experiences and backgrounds (Gordon, 1995). The role of the Black male teacher as a role model extends beyond what they can do for students in school. The Black male teacher as a role model can also have a positive impact on the development of Black students, as adults. As Foster (1991) explained, Black male teachers who serve as role models can reinforce cultural norms of the community. Black male role models often hold Black students to expectations that exceed those of the broader community (Foster, 26 1991). The growing challenges that many Black boys face has created an increased need for Black male teachers as role models. Lynn (2006) highlighted the correlation between positive male role models and the elimination of the barriers faced by Black boys, including racism, poverty, discrimination, incarceration, and high school dropout. Irvine (1988) noted that White students could also benefit from Black teachers as role models. There are benefits to having Black male teachers as role models, not just for Black students, but also for students of various backgrounds (Smith et al., 2004). Black Male Teachers as Disciplinarians Due to the challenges in and out of school that many Black boys face, the push for more Black male teachers comes from a place of needing them to serve first as disciplinarians and as teachers, second (Bristol & Mentor, 2018). Black male teachers often perceive their peers and school administrators to expect them to become experts on all things Black (Bristol & Mentor, 2018). They are often forced to assume the role of the enforcer or disciplinarian. Bristol and Mentors (2018) study of 27 Black male teachers in Boston revealed Black men had to attend to students social and emotional development, which influenced their capacity to engage and manage perceived misbehaviors by students. When the few Black male elementary teachers must do more of the enforcing than educating in the classroom, their teaching qualifications are undermined. The high suspension rates of Black students lead many Black teachers into the roles of deans and behavioral specialists. Often, Black teachers feel as though their school leaders see them as disciplinarians first and teachers second (Barnum, 2018). Many school leaders observe Black male teachers abilities to relate to Black students without raising their voices and perceive 27 them as tough and strict instead of as individuals who found opportunities to connect and help students (Tomlin, 2021). When it comes time for promotions or advancement, a disproportionate number of Black men are recommended to or hired in disciplinarian roles instead of academic roles (Brockenbrough, 2015). Data shows that Black boys in elementary schools across the country are twice as likely to be suspended than their Latino and White classmates (Catalyst Chicago, 2010). These suspension numbers speak to what happens to many Black males when they enter the classroom as teachers, as they are expected to help curve the data of suspension for Black boys. Multiple researchers have cited the overreliance on Black male teachers as disciplinarians in schools that serve large populations of Black students (Bristol & Mentor, 2018; Brockenbrough 2015; Brown, 2009; Young & Young, 2020). Brown (2009) believed the perceptions as Black men as disciplinarians comes from the label that Black men and boys are oppositional to the norms and expectations that exist in schools. These perceptions then lead to the disproportionate suspension of Black boys. Young and Young (2020) stated that perceptions of Black men as disciplinarians is not just harmful to Black male teachers who want to be seen as content experts, but also to the other teachers who are absolved from the responsibilities of classroom management. The Black male teacher is called upon to handle the discipline due to perceptions that they can successfully redirect the Black student because they are Black and male, and the student will better respond to them (Bristol & Mentor, 2018). These expectations could be the byproduct of expectations that Black male teachers fill the gap for fatherless homes. 28 Black Male Teachers as Surrogate Fathers This section discusses how Black male teachers compensate for what is missing in the students homes. Carr (2002) suggested that Black male elementary teachers can compensate for the lack of strong male role models in Black students homes. Many Black youth grow up in women-led households; in 2019, 64% of Black children grew up in a single-parent household (Kids Count Data Center, n.d). Black male teachers in the classroom can compensate for the absence of Black fathers at home, who are supposed to be the protectors, providers, and disciplinarians (Carr, 2002). A teacher cannot replace a Black father in the home, but they are the next best option for many Black students. Black teachers who stand in front of Black children for six hours a day, five days a week, for seven months out of the year are vital to their development (Carr, 2002). By serving as surrogate fathers, Black male teachers can bridge the gaps that exist for Black students between the experiences at home and the experiences at school. When Black male teachers serve as surrogate fathers, they can help their Black students navigate institutional racism that society often characterized with Black students who grow up fatherless (Bristol, 2014). Cash (2021) concurred with this notion, suggesting that students benefit from seeing Black teachers in bodily form, even if interactions are limited. The Black male teacher often serves in the father role for at-risk, fatherless students. Black male teachers as father figures are not just needed for Black boys, but for all children. For example, Morgan (1999) stated that Black American is quickly becoming a nation of fatherless daughters. Very little attention is paid to the significant role Black men play in shaping their daughters ideas about themselves and love (Morgan, 1999). 29 Brockenbrough (2011) noted that Black male teachers are identified as father figures and their other fathering practices are associated with their culturally relevant pedagogies. He noted that six men from his study pointed to deep connections with Black male students as the central aspect of their work as Black male teachers (Brockenbrough, 2011). While many embrace the role of father figure as Black male teachers, others from the study expressed anxieties. Brockenbrough explained that despite scholarly and media depictions, seven of the eleven participants described the role of father figure as an extrapedagogical responsibility. Some participants specifically expressed that it was not their job to assume a father role for their students (Brockenbrough, 2011). Black Male Teachers as Symbols of Diversity Increasing the number of Black male teachers at the elementary level will increase equity and diversity in the profession. Multiple researchers have described the importance of Black teachers to Black students (Bristol & Mentor, 2018; Brockenbrough, 2009; Young & Young, 2020;), but they impact White students, as well. Black teachers impact White students as they expose them to the diversity that exists in the world (Irvine, 1998). Curry (1986) explained that education has been the means for African Americans to help themselves. While education was easier for Whites, many Blacks had to pursue their learning in secret. Curry believed that African Americans emphasized education because they lacked other means of advancement, such as influential family members, access to capital, and living environments free of constraints. The importance of education for African American dates back long before Black people were forced into slavery in the New World. In Africa, many societies believed in the importance of education for young 30 children. Education and teaching were considered sacred duties. It was important for children to be educated, as this promised them better lives. Historically, the Black community has regarded teaching as a noble and wellrespected profession. Irvine (1989) and Maylor (2009) pointed to the vital role that Black teachers play in the lives of their students especially Black students. Irvine (2004) described Black teachers as having a cultural eye that allows them to connect with Black students through shared cultural backgrounds. The cultural eye allows Black teachers to have more success with Black students, fostering better academic outcomes. The cultural eye is about teachers demonstrating the ability to recognize their students backgrounds and create classroom experiences and instruction that align with those backgrounds. Black teachers also understand how non-classroom issues, such as a lack of food in the house, lower socioeconomic status, and poor at-home living situations can undermine the achievement of Black students (Mitchell, 1998). For many Black teachers, success in the education profession can be attributed to cultural capital, a term Pierre Bourdieu introduced in the 1970s (Bourdieu, 1984). Bourdieu referred to cultural capital as the social and cultural knowledge that can help students make progress (Bourdieu, 1984). Bourdieu stated that cultural capital can exist in three forms: in the embodied state, the objectified state, and the institutionalized state (Richardson, 1986). Cultural capital is about the experience, exposure, knowledge, and educational advantages over others who have not acquired it, had it transmitted to them, or had it handed down to them (Fant, 2017). Fant (2017) described Black teachers as being able to affirm the voices, viewpoints, and worldviews of their Black students in the classroom. For Black teachers in the education profession, the idea of cultural capital is 31 important for three reasons: (a) it helps Black students develop a strong sense of identity; (b) it encourages a love of learning; and (c) it builds trust and cooperation. Black students develop a strong sense of identity when their teachers help them feel more connected to who they are and where they come from. This encourages their love of learning because students show more interest in learning from teachers who look like them and understand them better. Trust and cooperation are built through recognizing shared backgrounds between teachers and students. Scholars have underscored the importance of having Black educators in the teaching workforce. Cherng and Halpin (2016) argued that Black students benefitted from Black teachers because those teachers have higher expectations of them and are more culturally sensitive than White teachers. This is even more important with the variety of traumas Black students face outside of school, such as police violence and the disproportionate impact of COVID-19, which drastically interrupted the education of Black students. Additional work is needed to strengthen the pipeline of Black teachers in U.S. schools so more Black students can receive a quality education and have better experiences in school. Black Male Teachers as Academic Influencers Bristol (2014) noted that Black males are the most socioeconomically disenfranchised group. Black males perform the lowest academically and have a higher rate of high school dropout than students of other races (Schott, 2010). Jones (2006) suggested that Black males can influence Black boys, who suffer more from academic underachievement and are generally less satisfied with school. Black male teachers provide Black students with more support for their self-esteem, their hopelessness, their 32 productivity dysfunction, and their low expectations in school. These supports can improve their performance in school. Having a Black teacher is important for Black students to perform academically. The representation of the Black teacher is important in academic achievement; however, it is more about the Black male teacher being an influencer of academic achievement. The most important factor impacting academic achievement for Black students is the expectations of the teacher (Kunjufu, 2002). There are studies that illustrate how Black teachers express to their students the importance of education within their larger social and political worlds (Brown, 2009). The Black male teacher who is an influencer of academics is the Black teacher who can provoke social and political change through pedagogical practice. Researchers have highlighted the importance of the pedagogical practices of the Black teachers on the academic achievement of Black students (Delpit, 1988; Foster, 1991; Irvine, 1990). Through research about the pedagogical practice, Brown (2009) discovered Black teachers abilities to engage in a variety of culturally based rhetorical strategies helped foster student learning. Through commonalities in culture and background, Black teachers who teach Black students can challenge and push them more than White teachers (Bristol & Mentor, 2018). According to a Vanderbilt University study, Black teachers are three times more likely than White teachers to refer Black students to the gifted program (Grissom & Redding, 2016). The study mentioned the fact that Black teachers provided more access to learning by not sending Black students to the principals office as frequently, and they challenged their Black student to reach new academic heights. There is a link between the race of the teacher and the assignment of students to gifted programs (Grissom et al., 33 2015). The Black male teacher as an academic influencer can push to see more Black students recommended for gifted program over special education programs. Participation in gifted programs have been linked better overall academic performance (Grissom & Redding, 2016). Of the various roles Black male teachers play, the role of academic influencer may be the most important of them all. Black Male Teachers as Change Agents Maylor (2009) noted that students of color who have Black male teacher role models often demonstrate improvements in their behaviors, aspirations, and achievements. Black male teacher role models can improve students outcomes, leading to a better school experience. Students cannot be what they cannot see. The push for more Black male teachers in classrooms does not suggest non-Black male teachers cannot impact student achievement and outcomes. However, research indicates Black male teachers can contribute greatly to the overall success of Black students. Thus, those responsible for hiring teachers must make the recruitment and retention of Black male elementary teachers a priority. Black male teachers position themselves as agents of change for students and their respective communities (Fant, 2017). The push to increase the number of Black male teachers as a reason for social change in the Black community emerged after the Million Man March (Dawson, 2001). The Million Man March highlighted the need for Black men to stand in unity with one another and take responsibility for themselves and each other to build responsible communities (How Black Academics Viewed the Million Man March 1995). The Black male teacher as an agent for change assumes that Black men can reach Black boys on a different level because they overcame the existential dilemma of being "Black and 34 male, and they possess knowledge they can pass down (Brown, 2011). As change agents, they provide knowledge that allows students to not only succeed in school, but also in life. Brown (2009) highlighted literature that successful Black teachers of Black students possess a commitment to social justice (Beauboeuf-Lafontant, 1999; Dixson, 2003; Foster, 1997; King, 1991; Ladson-Billings, 1994; Lynn, 2002). Black male teachers as change agents achieve a level of success with their students by relying on social justice through education. The role of the Black male teacher as an agent of change is exercised in a variety of ways. As Brown (2009) concluded, the Black male teacher is not a monolith. Black male teachers have varied perspectives and beliefs that they employ when they are teaching Black students. While Black male teachers may hold similar commitments to changing both the academic and social outcomes of Black students, they approach that change in a variety of ways. As previously mentioned, Black male teachers are agents of change through their roles as disciplinarians, surrogate fathers, and academic influencers. Black Male Teachers as Tokens The theory of tokenism was founded by Kanter (1977), whose research was focused on skewed sex ratios and responses to women. Kanter developed a framework to conceptualize the process that occurs between dominants and tokens. Kanters data collection and analysis were focused on the representation of workers in one organization. The theory of tokenism explores situations in which men and women operate as tokens (Kanter, 1977). For Black male teachers, these spaces could include schools, especially at the elementary level. While this dissertation was not centered on 35 tokenism, it is useful to conceptualize the notion that Black male elementary teachers are often considered tokens. Bristol (2014) addressed the implications for racialized tokens by discussing gender and focusing on performance pressures, boundary heightening, and role encapsulation. Bristols reference to performance pressures faced by Black male teachers at the elementary level may result in what Kanter (1977) described as either overachievement, intentionally making one appear less threatening, or trying to become invisible. Kanter suggested that boundary heightening occurred when both tokens and dominants were aware of their differences and interacted based on those differences (Bristol, 2014). In the case of Black men at the elementary level where they are outnumbered, Kanters (1977) theory positions the Black male teacher as the bridge between the school and the community, thus forcing Black male teachers to isolate themselves from the rest of the school because of this added pressure. Bristol (2014) focused on Kanters idea that tokens face role encapsulation. This means they are required by dominant groups to serve in familiar and stereotypical roles. Bristol described a study by Hasse (2010), which focused on male primary teachers who negotiated gender in a predominantly female setting. The men in the study described how they were disproportionately asked to serve in roles as coaches and disciplinarians. Their failure to accept these roles subjected them to assumptions that they were gay or had pedophilic tendencies (Hasse, 2010). There are some benefits to describing Black males at the elementary level as tokens. Research by Kelly (2007) countered the theory that Black teachers only faced negative experiences in majority White spaces. Using Kellys expansion of Kanters 36 (1977) theory, Black male teachers who are successful as elementary teachers could expand the issues of policy and practice in the teaching profession. Kelly described how Black teachers used the status of tokens to transcend racism through racial integration and personal contact. Tomlin (2021) believed Kellys approach was better for achieving equity. The works of Kanter and Kelly offer insights into how the Black male teacher at the elementary level can experience tokenism as both a burden and a benefit. Gender Norms at the Elementary Level Williams (2017) data on the national level indicated male teachers were underrepresented in the elementary grades. The data shows that teaching is a womandominated profession. In the past, teaching was a career for men. According to Apple (1988), elementary school teaching became a womens profession when men left to work in more industrial fields. Some of the greatest educators of the past were Black men, including Booker T. Washington, Frederick Douglass, and W. E. B. DuBois. Around the mid-19th century, during the birth of the countrys public school system, the gender composition shifted to become majority women (Wong, 2019). However, the high school teacher make-up was still majority men until the late 1970s (Ingersoll et al., 2014). Brockenbrough (2012) explored the idea of how the Black male navigates gender norms while teaching. Brockenbrough discovered three themes: inattention to male privilege, their conflict with women colleagues and administrators, and their desire to work in more male-centered spaces. This research also highlighted the complicated relationship between Black male teachers and women administrators. Brockenbrough described the realization that Black men were aware of how their gender influenced their relationships with women administrators. Brockenbrough only built on the literature that 37 explored the challenges that Black men faced in environments dominated by woman. Brockenbrough described how Black male teachers believed female administrators made efforts to emasculate them in the school environment. Participants recognized they had a blind eye to the impact of male privilege, as the maleness was a source and site of power (Brockenbrough, 2012). Brockenbroughs participants spoke about the possibility of working in spaces where they could be connected to more men and expressed preference for male principals. Many teachers across the country feel overworked, underpaid, and underappreciated (Camera, 2019). These feelings do not bode well for the push to get more men to consider teaching, especially at the elementary level. In consideration of the push to attract more men into elementary teaching positions, masculinity and occupational prestige go hand in hand (Laib, 2021). According to Laib (2021), men do not seek jobs known to be low on the social status totem pole. The need for men to be head of the household and take care of their family the occupation of an elementary does not necessarily make that possible. The pressures that exist to maintain a level of masculinity makes it difficult for men to balance the characteristics ascribed to elementary teachers (Medford et al., 2013). According to gender theory, Medford et al. (2013) argued men are often uncomfortable filling roles such as elementary school teachers. Greenberg (1985) described social equity as a focus on the education at the elementary level as a profession. Social equity can help eliminate stereotypes that teaching at the elementary level is only for women. Social equity is not about specific qualities of male teachers or what they can provide to students, but about their presence 38 in the classroom (Seifert, 1988). Social equity could increase the number of Black males working with younger students and change the mindset of those who see teaching as only work for women. Perceptions of Black Male Elementary Teachers Teaching is one of the most underappreciated fields of employment in the United States (Camera, 2019). Many people hesitate to visualize teachers as Black males, instead picturing Black men as athletes. However, Black male teachers are important for helping Black students to see themselves mirrored in their educators. There is a growing concern about the lack of Black male teachers in the United States, especially in schools with a significant number of Black students. However, little research exists on why Black educators choose to teach at the elementary level. Young and Young (2020) noted the underrepresentation of Black men in elementary school positions, explaining the trend was nationwide. The Merriam-Webster (n.d.) online dictionary defines the word undervalue in two ways. The first is to value or estimate something below its real worth. The second is to treat something as having little value. Black male teachers are often undervalued for their work and are called unicorns in the teaching profession. The term notes how rare and highly valuable Black male teachers are in the classroom, especially at the elementary level. It seems that students in the classroom see the value in Black male teachers, but school administrators do not see this same value. Far too often, Black male teachers feel less valued than their White counterparts or Black women teachers. In the Teach Plus and Education Trust groundbreaking study (2019), titled If You Listen, We Will Stay, teachers of color described feeling undervalued as such: Teachers of color also feel that 39 at the same they are being marginalized, they are being asked to take on greater responsibilities and roles because they often share (or are perceived to share) similar demographic backgrounds with their students (p. 9). African American Males Path to Teaching A variety of factors contribute to the challenges African American male teachers encounter on the path to teaching. Many of those factors are not just educational challenges, like dropout rates and the lack of representation during their K12 experience, but also societal factors such as high incarceration rates, unemployment, police violence, and family pressures. The lack of Black males in education is also due, in part, to the fact that society applauds the athletic abilities of Black boys and men over their intellectual capabilities. The stereotypical image of Black men can be traced back to slavery (Jones & Jenkins, 2012). Jones and Jenkins (2012) also noted that the young Black men increasingly internalize popular views about how they are lazy and unaccountable. While the K12 educational experiences for some students is a time of self-discovery, meeting people, and a safe-haven, for Black boys, the school experience can be worse than the neighborhoods and homes in which they grew up. Before a Black man can get to the classroom to teach, they first must navigate the K12 system. The K12 educational experience for many Black boys is filled with trauma and demoralizing experiences, so they do not want to return to that environment. Lynch (2017) described the Black youth experience in K12 education as a crisis that begins at home, stretches through the entire K12 educational experience, and fosters a cycle of incarceration. For many Black boys, the school systems are not paths to college, but one-way tickets to the prison system. Improving the K-12 educational experiences for 40 Black youth must be a first step in attracting attract more Black men into elementary teaching positions. Black youth face two harsh realities when it comes to their K12 education experiences. First, they are more likely to be suspended from school or receive harsher punishments. In the 2014 School Discipline Report produced by the U.S. Department of Education Office for Civil Rights, Black children represented just 18% of preschool enrollment; however, 48% of this population received more than one out-of-school suspension (Gassaway, 2017). The unfair and harsh punishment of Black boys leads to lower academic performance. According to research published by the American Psychological Association (APA, 2021), Black students who are subject to harsher punishments than their White peers lose interest in school, which causes them to perform lower academically. The second harsh reality Black youth face during their K12 education experience is that they are more likely to be recommended for special education. Too often, especially in the early grades, Black boys are labeled with certain perceived disabilities at higher rates than their White classmates. Many are labeled as having attention deficit hyperactivity disorder (ADHD) as early as kindergarten (Lynch, 2016). The lack of understanding about how Black boys at the ages of five and six interact with their peers and behave in certain situations causes schools and teachers to label and refer them to special education. Black boys are more likely to be placed in special education classes than any other group (Lynch, 2016). The K12 experience for Black boys can be described as one of more failure than success. Many Black boys enter school with the energy of typical children, excited to 41 learn and ready to explore the world with a healthy level of confidence (Noguera, 2008). Despite this, the school setting does not embrace the attributes of Black youth. If this is the case, how can the expectation be for Black men to become teachers in that system? Other reasons that Black men do not enter careers in teaching include low pay and gendered perceptions (Wiest, 2003). Rice and Goessling (2005) stated that men often fear teaching careers will be viewed as effeminate or homosexual. Instead of being pushed toward careers in teaching, Black boys are often pushed towards other things while growing up. Many adolescent Black males are encouraged to pursue sports over academics (Whitmire, 2010). In the highly controversial book titled Darwins Athletes: How Sports has Damaged Black America and Preserved the Myth of Race, Hoberman (1997) discussed the experiences of Black male youth and their parents. Hoberman highlighted how sports have led many African Americans to embrace the damaging idea that physical self-expression is the essence of being Black (Valentine, 199). Beamon (2010) highlighted four factors that lead Black boys to sports over anything else, including teaching. Those factors included family, role models, neighborhood, and the media. Regarding family, Beamon mentioned how one participant in the study was encourage by their family to focus on sports because it would lead to a college scholarship. Despite being excellent students in school, the family serves as the earliest and most influential socializing agent into sports participation (Beamon, 2010). Felton (2022) cited a 2011 National Education Association study that found, despite prior academic achievement, high-performing Black students were 2.5 less likely to be enrolled in gifted and talented programs. 42 The Role of HBCUs in Training African American Male Teachers The role of Historically Black Colleges and Universities (HBCUs) in training African American male teachers cannot be understated. For many years, HBCUs have been at the forefront of African American education programs. During the 1800s, when the majority of HBCUs were established, they served as pre-collegiate schools for newly freed slaves and as normal schools for the training of teachers. HBCUs may comprise only 3% of all 4-year colleges and universities; however, they produce almost 20% of all Black college graduates (Seymour & Ray, 2022). As the need for more Black teachers increases, HBCUs will be even more important in their recruitment and training. According to Irvine and Fenwick (2011), The impact of School of Education (SOEs) at HBCU is indisputable. They graduate 50% of African American teachers with bachelors degree. The United Negro College Fund (UNCF) reported in 1998 more than half of all prospective Black teachers in Missouri, Maryland, Louisiana, Virginia, South Carolina, North Carolina, Delaware, Alabama, and the District of Columbia were trained at HBCUs. (p. 1) There was a period in history when many higher education institutions would not admit African American students. Thus, HBCUs became the best place for Blacks to receive a quality education and played a major role in diversifying a majority White teaching force in the United States. HBCUs played an important role in the Black community, especially during the Jim Crow era. Teachers from HBCUs protected Black students from overt racism while still encouraging them to push forward. These teachers were vital to the success of 43 students who came from backgrounds of low expectations, racism, and poverty. The United Negro College Fund (UNCF) partnered with the Annenberg Foundation to create the HBCU School Linkage Program, which is a 3-year, $2 million dollar grant. The grant supports the Program in providing direct support to selected, eligible UNCF-member institutions to help improve the recruitment and retention of minority students who demonstrate an interest in pursuing careers in teaching. These programs are vital to ensuring HBCUs continue to lead the way in producing more Black teachers. The majority of HBCUs were founded as teachers colleges. According to data from the National Center for Education Statics (NCES), the top producers of teachers are Alabama A&M University, Alabama State University, Albany State University, Elizabeth City State University, Fayetteville State University, Jackson State University, Mississippi State University, North Carolina A&T State University, Tennessee State University, and Virginia State University. HBCUs are needed to recruit more Black male teachers by offering recruitment, training, and support. HBCUs offer support with recruitment in the following four ways: by easing the cost of school, through their community focus on teaching, through alumni teaching support, and through targeted initiatives to support Black males. Many Black males struggle with the cost of tuition, which can create barriers in education programs. HBCUs on average have a lower tuition than predominately White institutions. Although HBCU students having higher loans than their peers at non-HBCU schools, they do report greater financial stability and a higher overall well-being after college (Seymour & Ray, 2021). HBCUs approach teacher recruitment with a sense of community and encourage teachers to be an integral part of the communities in which they teach. Many 44 HBCUs encourage teachers to go teach where they grew up. This sense of belonging leads teachers to believe more in the high achievement of their students as they were once those students, as well. At some HBCUs, students can receive certificates after graduation to teach in the communities where they were trained. HBCUs also provide alumni support to help prevent early career burnout. Garcia and Weiss (2019) highlighted the importance of community support for helping novice teachers manage their first few years in the profession. Howard University and The Thurgood Marshall College Fund both have initiatives geared toward providing Black teachers with mentorship, advice, and professional development. HBCUs lead the way in providing initiatives to support Black men through programs with scholarships. Alabama A&M University offers support through their Males for Alabama Education Initiative Scholarship. Those who are eligible can receive financial assistance with tuition, books, and assessments. Another great program is a collaboration between HBCUs University of Arkansas Pine Bluff, Southern University, Alcorn State University, and Claflin University, which is called the Project Pipeline Repair. The program recruits men of color into teaching through skills development, application support, and an emphasis on social justice. HBCUs are also leading in the development of alternative programs. One such program is The Ready to Teach Program at Howard University, which Irvine and Fenwick (2011) believed could be a leading program to recruit Black males in high-need schools. Funded by the Department of Education, the program partners the Howard University School of Education with five urban school districts in Chicago, Illinois; 45 Clayton County, Georges; Houston, Texas; Prince Georges County, Maryland; and Washington, D.C. (Irvine & Fenwick, 2011). Teaching Programs That Support African American Males A growing number of programs across the country are dedicated to the recruitment of African American male teachers. The best way to recruit teachers is early, having them go through a 4-year college and university to be traditionally trained; however, many Black men become teachers as career changers. While the Grow-YourOwn model is a popular model for recruiting more teachers, it requires the recruitment of Black males to begin in high school. Typically, Black males in high school are not interested in becoming teachers. The lack of representation they encounter and the overall school experience for Black males does not make teaching an attractive profession. While recruitment is an important first step, the second step arguably the most important step is the retention of Black male teachers. Wicker (2020) suggested that the retention of teachers is a critical challenge, nationwide. It is not good enough to recruit a large amount of Black male teachers to schools and classrooms without ensuring they stay in the profession, long-term. Black male teachers cannot make an impact in just 1 or 2 years; it takes year of commitment to yield the results necessary for Black children. According to the Council for Educational Change (2018), retention programs consist of the following: residency programs, workshops, mentoring, cultural pedagogy, school site visits, and independent evaluations. There is a growing movement to recruit and retain African American males in specialty programs, both at college campuses and after they graduate from college. 46 Teach for America Teach for America (TFA) founder Wendy Kopp opened her book, A Change to Make History (2011), with the following account of how she dreamed up the idea for TFA: I envisioned our generation rallying to address the unjust reality that even in our nationa nation that aspires so admirable to be a place of equal opportunitythe neighborhood into which children are born still largely predicts their educational outcomes and, in turn opportunities in life. (p. 1) Since 1990, when TFA was launched with 489 corps members in New York, Los Angeles, Eastern North Carolina, South Louisiana, and rural Georgia, the goal was to take the highest achieving and motivated young professionals and to place them in the countrys most high-priority schools. TFA wanted to level the playing field to ensure that all children had the potential to be taught by highly effective teachers who believed in their potential and who wanted them to receive an excellent education. TFA only requires a 2-year commitment, but it believes the 2-year commitment can have a lifelong impact (Kopp, 2011). TFA is also where two TFA-institute roommates met and created an idea for a non-profit, Profound Gentleman (PG), which garnered national recognition for its work supporting Black male educators. Mario Jovan Shaw and Jason Terrell founded PG in 2012 when they were TFA members. Zingg (2018) reported that PG has served roughly 225 male educators of color across the country; during the year 20172018 school year, 100% of those teachers decided to stay in the classroom the following year. In 2020, TFA launched a 5-year initiative that was funded by the Ballmer Group and aimed to recruit 47 and retain Black educators. This initiative was called the Black Educators Promise Initiative (BEP) (TFA, 2020). The goal of BEP is to increase understandings of what resources are needed to support Black teachers and ultimately to increase the number of Black teachers in the field. The initiative supports Black teachers in TFA if they agree to stay in the field, offering funds to cover costs for certification and testing. For many Black teachers, especially Black males, the certification, and testing requirements are barriers to entry and retention; the BEP seeks to remove that barrier. Call Me MISTER Roy Jones and Aretta Jenkins (2012) have written about the mission of Call Me MISTER: We believe that Call Me MISTER is indeed in the vanguard of a fourth crusade to ensure a quality education for Southern Black children, building upon the advances of earlier generations (p. 95). Call Me MISTER stands for Mentors Instructing Students Toward Effective Role Model Programs (Jones & Jenkins, 2012). Call Me MISTER was designed as a homegrown approach to recruiting, developing, and placing teachers. The program was founded in 2000 at Clemson University (Jones & Jenkins, 2012). Jones and Jenkins observed that Call Me MISTER never saw the program as national or global, but rather focused on the shortage of Black male teachers, especially at the elementary level, in South Carolina. Call Me MISTER wanted to draw on the pool of students in the state and develop them to have them stay in-state to teach in public schools. During the late 1990s, less than 1% of South Carolinas public-school teachers were Black males (Lennon, 2016). Through the collective work of educators, elected officials, civic and business leaders, superintendents, principals, and financial advisors, 48 the vision and initiative for Call Me MISTER were founded (Jones & Jenkins, 2012). Call Me MISTER began by establishing partnerships with private colleges with a history of developing Black teachers. By 2004, the organizations partnership was expanded to include a select number of candidates from historically White colleges and universities (Jones & Jenkins, 2012). As Call ME Mister was beginning to receive national attention and widespread funding, the local vision was beginning to look small. Thanks to a donation from Oprah Winfrey and a feature on her show, some of the first graduates from the program, in 2004, were known as the Oprah Cohort (Nicholson, 2020). Two decades later, the percentage of Black male teachers in the state has increased from 1% to 2.8%, thanks to the efforts of Call Me MISTER (Nicholson, 2020). Call Me MISTER has 10 national partner schools in other states, including Florida, Louisiana, Georgia, North Carolina, Tennessee, Illinois, Texas, Kansas, Kentucky, and Virginia. The Call Me MISTER program wanted Black males to see teaching as a true calling. According to Jones and Jenkins (2012), we raise teaching to the level of a calling. Teachers have an impact that lasts for generations, and those impacts transform communities (p. 97). Summary The reason why African American male teachers do not choose to teach at the elementary level is complicated. The literature discussed in this chapter highlighted the variety of roles Black men play as teachers at the elementary level. Many of the roles are due to a combination of historical and societal factors that have made life difficult in this country for African American males. 49 Jones (2006) believed the shortage of Black males at the elementary grades places children at a disadvantage, especially for boys. Black men serve as role models, surrogate fathers, academic influencers, symbols of diversity, and change agents. This is especially true for students in the elementary grades. Most children spend a great deal of their waking hours in schools; during the elementary years, it is important to have Black male teachers to foster development (Hicks Takari, 2018). The K12 experience of many African American boys is another barrier to their journey to teaching. Research indicates some women teachers interpret specific behaviors of male students as challenging and unsafe (de Zeeuw et al., 2014). At the elementary level, this is particularly important because many male students begin to form their notions about school during these years. The presence of more Black men in U.S. schools can fill the gap in a system that fails African American children. As the K12 system fails Black youth, jails and cemeteries become more of a destination for African American boys than do classrooms. As Nellums and Milton (2013) wrote: As Black men we have given away the one responsibility that our culture deems essential to the survival of our race- rearing Black boys. Our generation must inform and teach young Black boys how to become productive Black men in the communities they call home. (p. 27) As many of the countrys Black youth struggle in school and life, many come to school to find the pieces that are missing from their homes. The impact of Black male teachers, especially at the elementary level, is an important foundation in for developing Black boys into men. Saving the K12 school experience may rest on the shoulders of the Black educators currently in the classrooms, as well as those who will soon follow. 50 CHAPTER THREE METHODOLOGY Introduction The purpose of the qualitative study was to examine why Black males decided to teach at the elementary level. Young and Young (2020) reported that qualitative research dominates research on Black male teachers. The study helped highlight the shortage of Black male teachers, amplified the voices of those who were currently in the teaching workforce, and raised awareness of the need to increase the number of Black male elementary teachers. Through participant interviews, a first-hand account was generated of their experiences and perceptions of the profession. In this chapter, the methodology of the current study is described, including a description of the participants, data collection and analysis, trustworthiness of the study, the role of the researcher, and member checking procedures. Connection Between the Theory and Research There can be a connection drawn between Maslows (1954) hierarchy of needs and the lived experiences of Black male elementary teachers. The first tier of physiological needs describes jobs that allow Black male elementary teachers to be paid salaries that provide them with basic wellness. Additionally, the salary must be adequate to make Black males feel secure about their abilities to provide for their families. The second tier of safety needs highlights the importance that Black male elementary teachers work in environment where feel safe and enjoy long-term job security. The third tier of belonging emphasizes the importance that Black male teachers feel valued and respected, despite working in a profession that is dominated mostly by woman. The fourth tier of 51 self-esteem emphasizes the need for Black male elementary teachers to feel a sense of accomplishment that fosters their professional self-confidence. Finally, the fifth tier of self-actualization highlights the need for Black male elementary teachers to experience professional and personal growth; they must feel their work has meaning. Research Questions The purpose of the qualitative phenomenological study was to examine why Black males decided to teach at the elementary level. This study was guided by the following overarching question: What are the lived experiences of Black male teachers that contribute to their motivation to teach at the elementary level? Using Maslows (1954) hierarchy of need, the following research questions were employed: RQ1: What physiological needs are met for the Black male teacher? RQ2: What safety needs of the are met for the Black male teacher? RQ3: How does the Black male teacher feel a since of belonging? RQ4: What self-esteem needs are met for the Black male teacher? RQ5: What self-actualization needs are met for the Black male teacher? RQ6: How did the Black male experience COVID-19 as an elementary teacher? Qualitative Methodology This study shed light on the low number of Black male elementary teachers and highlighted the important role of African American males in the lives of elementary students. The study elevated the voices of Black male elementary teachers. To accomplish this goal, a phenomenological approach was used. A phenomenological approach is used by qualitative researchers to examine participants lived experience (Creswell, 2007). The intended goal is to understand and give them meaning (Byrne, 52 2021). According to Byrne (2021), phenomenology involves the systematic collection and analysis of narrative data, using methods that ensure the credibility of study results. Phenomenological researchers use phenomenology to understand better the essential truths of participants lived experiences (Byrne, 2021). In the current study, the goal was to better understand the meaning of their experiences of Black male elementary teachers, through the lens of Maslow's (1954) hierarchy of needs. This approach allowed for an indepth examination of the lived teaching experience of Black male teachers at the elementary level. Phenomenology as a research design is uniquely positioned to allow learning from the experiences of others (Neubauer et al., 2019). The relationships between Maslows hierarchy of needs and the lived experiences of Black male elementary teachers shed light and provided a better understanding of the Black male elementary teacher experiences, through a lens of non-deficit. Participants The researcher selected seven participants for the purposes of this study based on select criteria. To be eligible for participation, individuals had to: (a) identify as an African American, (b) identify as male, (c) teach at the elementary level, (d) teach a content position, and (e) have taught at least 1 year in elementary school. For recruitment to be successful, the researcher cast a wide net for participants across the United States. As such, it was important to connect with organizations across the country that worked primarily with Black male elementary teachers to locate individuals who met the inclusion criteria. An exploration of the lived experiences of African American male elementary teachers was essential to answering the research questions. With such a small population 53 of Black male elementary teachers in the United States, few limitations were placed on participation. By allowing a wide range of teaching experiences, this study uncovered a variety of thought due to the differences in professional experiences. This approach countered the narrative that portrays the lived experiences of Black male teachers as monolithic. Selection of Participants The researcher used the Marian University ProQuest website to find a variety of dissertations and articles related to the current study. The researcher selected three dissertations to use as a reference to finalize the specific criteria for selecting study participants. One of the dissertations was a portraiture study. Additionally, the researcher used research articles on portraiture studies to gain a better understanding of how to select the participants and to outline inclusion criteria. Using online research and social media, the researcher identified a list of organizations that worked to support Black male teachers. The researcher did not use participants they personally knew but recruited individuals through personal relationships and professional contacts. Two organizations that stood out were Profound Gentleman (PG) and the Center for Black Educator Development (CBED). Profound Gentlemans mission is to build communities of male educators of color who have a profound additional impact on the communities they serve (PG, 2022). Profound Gentleman supports Black male educators across the country. The Center for Black Educator Development is based out of Philadelphia, Pennsylvania, and its vision is to ensure all Black students have consistent access to high-quality, same-race teachers throughout their PreK12 experience (CBED, 2022). The Center for Black Educators Development 54 hosts a conference each year focuses specifically on Black male teachers. The researcher used both organizations to locate eligible participants by reaching out to them and asking for them to share the study with others their networks. Number of Participants Based on the relationships and connections the researcher established with PG and CBED, the goal of seven participants was attainable despite the low percentage of Black male elementary teachers across the country. In qualitative research, recommendations for sample size depend on the study method and design (Guetterman, 2015). Seven was an adequate sample size for providing appropriate context in the current study. Recruitment of Participants The researcher used PG and CBED to help recruit participants who met the research criteria. Additionally, social media websites like Facebook, Twitter, Instagram, and LinkedIn were utilized to share information and recruit participants. Professional organizations, including Divine 9 Greek Fraternities, Education Leaders of Color (EdLoc), and Surge were also used to identify study participants. The researcher recruited individuals from across the United States, with a primary focus on teachers from the Midwest and South. Background of Participants The background of the participants was an important part of their lived experience in this study. To provide meaningful context, the researcher gathered the following data on participants backgrounds: (a) geographic location, not including state or city, (b) 55 school type, (c) content level taught, (d) years of experience, and (e) teaching pathway type, either traditionally trained or transition to the teaching program. All seven participants had backgrounds either from the South or the Midwest. The representation of Black male teachers varies significantly between those teaching in the Midwest and those teaching in the South. Black males who teach in the South and Midwest of the United States represent an underrepresented population in the teaching profession. Research has shown that the representation of Black male teachers in these regions is significantly lower than their White counterparts (Ingersoll & May, 2011; National Center for Education Statistics, 2016). Research has highlighted disparities in teacher demographics across different geographic areas. Multiple studies highlighted the positive impact of Black male teachers on students, especially Black male students. Black male teachers can serve as role models and mentors, helping to narrow achievement gaps and improve educational outcomes for students of color (Dee, 2004; Jackson & Bruegmann, 2009). In regions like the South and Midwest, where racial disparities in education persist, the presence of Black male teachers can be particularly impactful. However, Black male teachers in these regions also face unique challenges. The South has a higher percentage of Black residents, leading to a slightly higher representation of Black male teachers than the Midwest (Ingersoll & May, 2011). However, it is important to note that even in the South, the representation of Black male teachers falls below the diversity of the student population, indicating an ongoing shortage of Black male teachers (Carver-Thomas & Darling-Hammond, 2017). In contrast, the Midwest has one of the country's lowest proportions of Black male teachers (Hanna, 2018). The demographic makeup of the Midwest, with a lower percentage of 56 Black residents, contributes to the underrepresentation of Black male teachers (National Center for Education Statistics, 2016). The scarcity of Black male teachers is a significant concern in the Midwest. The disparities between the two regions in the representation of Black male teachers underscore the importance of addressing recruitment and retention efforts on a local level. It will be important for the educational leaders and policymakers in both the Midwest and the South to recognize the significance of this issue and implement strategies to increase the presence of Black male teachers in their respective regions. This underrepresentation has important implications for both students and the education system. Research suggests that addressing these challenges and promoting the recruitment and retention of Black male teachers in the South and Midwest is critical to advancing educational equity and fostering diverse and inclusive learning environments (Irvine, 2003; Palmer & Maramba, 2011). The representation of Black students in elementary schools in the Midwest compared to the South highlights a significant demographic contrast. The South has historically had a higher percentage of Black residents, leading to a larger presence of Black students in its elementary schools. According to data from the National Center for Education Statistics (NCES), as of 2018, the percentage of Black students in public elementary schools in the South was approximately 26%, significantly higher than in the Midwest, where the percentage stood at around 17% (NCES, 2018). This disparity in student demographics reflects historical patterns of migration and demographic trends. If one were to consider The Great Migration of the early 20th century, Black families moved significantly from the South to other regions, including the Midwest. The legacy 57 of Jim Crow segregation laws and other historical factors meant that the South retained a larger Black population, resulting in more Black students in schools. In conclusion, the representation of Black male teachers in the Midwest and South is a topic of significance within the education field. Their presence can have a transformative impact on students, particularly those of color, while presenting unique challenges that must be addressed to support their success as educators. It is important to understand these disparities in student demographics for the Midwest and South when researching Black male teachers, specifically those who teach at the elementary level. Data Collection Data collection in qualitative research is more flexible than in quantitative research. Qualitative data gathering is not limited to one method (Creswell, 2013). There are various methods of qualitative data collection, such as individual interviews, focus groups, questionnaires, and field observations. Researcher should select data collection strategies based on participants characteristics, data collection sites, access to participants, and the type of data they are collecting (Wilson, 2013). In the current study, data were collected via interviews. Collecting data through interviews is the most direct and straightforward approach to gathering detailed, rich data (Barrett & Twycross, 2018). This researcher conducted interviews to allow participants to recall their lived experiences while teaching at the elementary level. The interview cycle was broken into three parts. The first phase served to break the ice between the researcher and participant. During this phase, the participant answered two questions: (a) who there were as men, and (b) who they were as educators. The second phase followed the interview protocol, which was guided by the research 58 questions. The final phase created an opportunity for participants to review their responses to the interview questions and add any clarity towards their answers, via member checking. The interview questions led participants on a journey (Dilley, 2000). Participants had opportunities to answer every question freely, and the researcher informed them that there was no right or wrong answer, only the experience they lived. If there was a need for more information, the researcher asked follow-up questions to ensure clarity and understanding, such as: (a) tell me more, or (b) can you repeat? The researcher recorded, transcribed, analyzed, and coded the data to identify themes. Recording interviews in qualitative research was useful before and after data collection, as it allowed the researcher to focus on listening, probing, and following up (Rosalind & Holland, 2013). Transcribing audio recordings is standard practice in qualitative research (Tracy, 2019). The software used to support in the transcribing of the interviews was Otter.ai. In qualitative research, coding speaks to how the data is defined (Gibbs, 2007). Coding is the process of identifying a passage in the text, searching, identifying concepts, and finding relations between them. Strauss (1987) believed that the excellence of research depended on the excellence of coding. The researcher conducted one-on-one interviews. Interviews were scheduled based on participants availability and were conducted virtually, via Zoom. The researcher provided participants with the interview questions prior to the interviews. In addition, written informed consent was collected prior to data collection. Data Analysis Qualitative data analysis is the process of providing order, structure, and meaning to the data collected (Marshall & Rossman, 1995). There are two distinct types of 59 qualitative data analysis considered for this study. The first was content analysis, which is the process of categorizing and tagging qualitative data for thematic analysis. It involves combining results with behavioral data to garner deeper insights (Hseih & Shannon, 2005). The second is narrative analysis, which uses interviews that tell a story and shed light on underlying events and their effects on outcomes (Riessman, 1993). For this study, the researcher used narrative analysis. After data were collected and transcribed, analysis was performed to identify the main themes. The researcher identified themes using repeated words, phrases, and patterns, and combining them to identify connections. It was important to identify themes that shed light on why Black males decided to teach at the elementary level. In qualitative data analysis, coding helps organize the data and develop themes (Creswell, 2013). Coding is considered the best way to analyze qualitative data and describes the use of tags or labels to assign units of meaning to descriptive data (Miles & Huberman, 1994). In this study, the researcher used manual coding. Manual coding involves reviewing the data and manually developing and assigning codes and themes (Saldana, 2015). During the manual coding process, the researcher employed inductive analysis; this allowed codes to naturally emerge from the data (Bingham & Witkowsky, 2022). There are multiple forms of inductive analysis, including open coding, which is often referred to as initial coding and in vivo coding. It develops from the words of the participants (Bingham & Witkowsky, 2022). Inductive analysis can help with: (a) making meaning from the data, (b) developing a theme, (c) identifying representative data to support the theme, and (d) explaining the theme using theory and literature. 60 The main themes to emerge aligned with each of Maslows (1954) needs and participants experiences teaching during the COVID-19 pandemic. The qualitative data analysis process allowed the researcher to condense data into themes that were aligned with the research questions. It was important to review the data repeatedly to ensure interviews accurately captured participants experiences. Trustworthiness and Credibility In a phenomenology, it is essential for participants to share deep and often personal stories about their lived experiences. In the current study, it was important for participants to openly share their experiences and decisions to teach at the elementary level. The researcher collected the stories and handled them in a delicate and sacred manner. It was critical to build the trustworthiness of the inquiry (Lincoln & Gaba, 1985). Leading up to the collection of data, researchers must establish relationships with participants to ensure they feel comfortable and openly share their lived experiences. It was important that each participant reviewed their interview transcript to ensure everything was captured as the participants intended. The researcher asked the participants to clarify their responses, if needed, to ensure the accuracy of the study data. All participants were assured that their personal information would be kept private and confidential. Unlike quantitative research, qualitative research has methods for establishing credibility in research. Credibility can be established by incorporating the following strategies: (a) accounting for personal bias, (b) engaging with other researchers, (c) data triangulation, (d) meticulous record-keeping, and (e) acknowledging bias in sampling (Noble & Smith, 2015). 61 Role of the Researcher In a qualitative study, the role of the researcher is to access the thoughts and feelings of study participants (Sutton & Austin, 2015). The role of the researcher is not easy, as they are tasked with asking participants about things that may be difficult for them to answer or very personal. The researcher is an essential component of the research process. Sutton and Austin (2015) highlighted how the researcher's primary responsibility is to safeguard participants and their data. Patton (2002) stated, "Because the researcher is the instrument in qualitative inquiry, a qualitative report should include some information about the researcher (p. 566). As the researcher, I brought my experience as a Black male and former school administrator responsible for hiring teachers. My own struggle to hire Black males at the elementary level led to an interest in discovering more about the Black male experiences and why some chose elementary instead of the secondary level. I have over a decade of experience in the K-12 setting, working at all school levels. I approached this study as a Black male researcher seeking to study the experiences of Black male elementary teachers. I recognized my bias and vested interest in discovering ways in which the role of Black male elementary teachers could be elevated in order to recruit more to the profession. I understood that I may have shared lived experiences with the participants. As a Black male researcher, my positionality may have clouded my ability to remain neutral during the analysis of data collected from the participants. Positionality describes an individual's worldview and position on a research task, and social and political context (Foote & Bartell, 2011). My vested interest in seeing results that yielded answers to my personal questions about the researcher needed to be 62 recognized before embarking on this journey. I understood my positionality could influence how the research was conducted, its outcomes, and results (Rowe, 2014) Member Checking Member checking is essential to establishing credibility in a qualitative study (Lincoln & Gaba, 1985). Creswell (1994) described member checking as a technique used to improve a studys accuracy, credibility, validity. Ass participants had opportunities to check and review their interview transcripts. Member checking can occur either formally or informally. An informal member check can occur during data collection, an interview, or focus group to check for understanding, or it can be done formally during a follow up interview, meeting, or conversation (Carl & Ravitch, 2018). The researcher offered to provide the participant with a copy of the interview transcripts for review, clarification, and suggestions, which occurred during the third interview. Summary The chapter provided insight into the specific methodology used throughout this research study. It contained the criteria of how participants were selected, including if they are: (a) African American, (b) male, (c) teachers at the elementary level, (d) teaching a content position, and (e) had taught at least 1 year in elementary school. The chapter addressed how the researcher used organizations like Profound Gentleman and Center for Black Educators Development to help recruit study participants. The chapter covered the steps for data collection and analysis, and described the studys trustworthiness and credibility, the role of the researcher, and member checking. Study findings are presented in Chapter 4. Chapter 5 offers a summary, conclusion, implications, and recommendations for future research. 63 64 CHAPTER FOUR FINDINGS Introduction Chapter 4 provides results of the study. The chapter presents the results of data collected from the qualitative phenomenological study conducted to explore the following six research questions: RQ1: What physiological needs are met for the Black male teacher? RQ2: What safety needs are met for the Black male teachers? RQ3: How does the Black male teacher feel a sense of belonging? RQ4: What self-esteem needs are met for the Black male teacher? RQ5: What self-actualization needs are met for the Black male teacher? RQ6: How did the Black male experience COVID-19 as an elementary teacher? The data from seven interviews were analyzed to identify the frequency of words in interviews related to the research questions. Data collected during the interviews were triangulated with documents and observations. This chapter includes (a) a description of the codes and themes derived from the interviews, and (b) an analysis of themes, which will be arranged to illuminate the response of the participants. Examples of open coding, code frequency, themes, subthemes, and codes are provided. At each level of analysis, a constant comparison was used to distill the data until themes emerged. Included in the chapter are tables used to present detailed code and theme data, as well as narratives from the individual interviews used to emphasize key themes and the resultant theory. 65 Participant Descriptions Seven participants were interviewed for this study. Table 1 illustrates participant demographics. All interviews were conducted via Zoom. Participants interviews were conducted between October and November of 2022. The first interviews lasted 20 to 30 minutes which consisted of two introductory questions: (1) who are you as a man and (2) who are you as an educator. During the second interview the participants were asked the interview questions which can be found in Appendix G. Those interviews lasted between 45 minutes to an hour based on the response length of each participant. Wes Wes described himself as a man who was laid back and reserved. Wes said he had moments when he could be outgoing, but for the most part he was a quiet person who liked to keep a low profile. When asked about his low profile, he expanded by saying, I am more observant than just a person who reacts off impulse. He liked to keep himself reserved as much as possible; however, he believed he was someone who could relate and get along with most people. When asked how he would describe himself as an educator, Wes said, I am a bit more outgoing especially when it comes to teaching my kindergarteners. When it comes to being around his students, Wes said he had to have big energy. Wes said that because of his demeanor of being laid back and reserved, he had to work hard early in his career to be more outgoing. He wanted his students to come in the room each morning and be excited and ready to go. He realized he had to keep his energy up in order to match their energy. 66 Horace Horace described himself using three words: humbled, fearless, and grateful. Horace was someone who was appreciative of all of lifes experiences. When asked about his role as an educator, Horace said, I am someone who is willing to do anything for the next generation. Growing up with both parents who pushed education on to him and his siblings, he saw the value of getting a good education, especially for a Black man. Horace was a proud graduate of an HBCU. He was motivated by the opportunity to lead and serve. With the tough work of being an educator, he found time to relieve stress by working out and smiling. When asked about smiling and why that was important for him, he said, Smiling helps release all my stress, all my cares, and I do not have to worry everyones expectation. I can just exist. Eugene When asked who Eugene the man was, the first words out of his mouth were a man of God. Faith was extremely important to Eugene, guiding him throughout his entire career and allowing him to pivot into education a little over a decade ago. Being an educator was not all that Eugene did, as he was also encouraged by the gatekeepers of his family to get off the sidelines. Eugene was active in the community and expanded his civic engagement. Eugene described himself as a father, husband, extrovert, and someone full of joy. Family was important to Eugene as his older sister motivated him to become a teacher, as she was also an educator. He came from a background of hand workers. Eugenes father taught him the importance of hard work, which is why this selfdescribed, hustler did not mind working multiple jobs. When asked about his hustlers mentality, he said, I will do whatever it takes to provide for my family. While 67 completing his hours as a student-teacher, he also worked an additional 40 hours at a dropout recovery high school and drove for Uber and Lyft. As an educator, Eugene said he wanted the students that everyone else had given up on. He wanted the students that everyone else believed would not succeed. He wanted the difficult students because those were the students for whom he became a teacher. Ralph Ralph was a first generation American. His parents were from Jamaica. He described himself as someone who was non-religious but very spiritual. Ralph got into education because his parents instilled the importance of learning. While his path was not traditional, he worked his way up to being a lead teacher, starting out as a teachers aide. Ralph was encouraged by those he worked with to pursue a career in teaching. He was passionate about protecting children and helping them learn so they could have better futures. When asked how he would describe his teaching style he said, I am someone who will do whatever I can to make a connection with a student in order to help them learn. Ralph wanted to help all his students learn about themselves and how they fit in the world around them. This was something Ralph himself learned and wanted the same for his students. Augusta Augusta was a Black man who taught in a rural school district in the South. He valued building relationships with his students, their parents, and their caregivers. The work of an educator was deeply passionate work for Augusta. When asked about his deep passion for education, he said he wanted, to make an impact not only for the Black males and minority students, but for all students in an effort to disband stereotypes 68 against, men of color who teach at the elementary level. As a man, Augusta was a family man and loved his wife and children deeply. He was a loyal man who encouraged others in all aspects of life. His faith was important to him as well. Herman Herman described himself as a man who was very intentional about his thoughts and his actions. He said he was a storyteller and believed he stood on the shoulders of the giants who came before him. His storytelling was about those telling stories of the past to those of the present who may not know them. He said he enjoyed the small and simple things of life. It was not just his approach that prevented classroom issues, but as he said, While I am serious as an educator when it comes to the pedagogy and the curriculum I can be laid back and I can make sure it relates to my students and they can find connections in in themselves in the things I am teaching them. Julian Julian understood the struggles of being a Black male educator so much that he worked with an organization to build connections and create a space for Black male educators to come together and share in fellowship. As an educator, his nurturing spirit did not just come with supporting other Black male educators, but also from his students in the classroom. As an educator, Julian could be very calculated and quiet, but his students knew he took their learning seriously and he could be firm when needed. Julian the man was a little more outgoing as he described himself as eclectic and someone with a broad range of interests. He was just as passionate about writing poetry as he was about teaching his students. A lover of the arts, he was someone who lived a colorful life. At 69 the heart of everything, Julian wanted to see real change in the world. Table 1 provides demographic information about each participant. Table 1 Participant Descriptions Participant Pseudonym Age Range Undergrad Attended Pathway Region School Type Grade Level Taught Years of Experience Wes 30-37 PWI Transition to Teaching Midwest Public Charter Kindergarten 4 Horace 30-37 HBCU Transition to Teaching Midwest Public Charter 5th Grade 7 Eugene 38-45 PWI Traditionally Trained Midwest Public School 6th Grade 13 Ralph 54 and older PWI Different Route South Public Charter 5th Grade 5 Augusta 38-45 PWI Alternative Certification South Rural 3rd Grade 13 Herman 38-45 PWI Traditionally Trained South Public School 6th Grade 12 Julian 30-37 PWI Different Route South Public Charter 5th Grade 7 Data Analysis The research design of the study was based on a qualitative methodology, as the researcher wanted to understand the lived experiences of Black male elementary teachers. The researcher gathered data through one-on-one interviews with seven Black male elementary teachers. After the interviews were transcribed, they were uploaded into Dedoose for analysis. The first step of analysis involved an in-depth review of all transcripts and journal responses, which allowed the researcher to become familiar with study data and begin identifying patterns in the data. Once the data were reviewed carefully, the open coding process began. Through open coding, a line-by-line examination of the data was conducted to identify codes. A code was represented by a 70 repeated idea, word, phrase, or sentiment shared by the participants. When a pattern was identified, it was then given a code name and was noted. Table 2 below provides examples of the open coding. Table 2 Open Coding Examples Excerpt from Data Allow me to understand the power of freedom, and to embrace who I was and not have to, you know, show up and be anything other than my authentic self. Coded as authenticity I come from a family of educators. So, most of us were up at the same time, you know, getting ready for work and being able to collaborate and you know talk about the day and debrief. Family members are educators As an elementary school teacher, I feel very secure. If I had to teach somewhere else at another school at the end of the year. I 100% know, I could land another teacher position. Good job security I always tried to say what I need to say. But the challenging part is having to be political about it. Cant speak freely Schools are run on norms of white middle class society. White cultural norms Fear of sexual accusations You have some woman who feel a certain way if they find you attractive and you may not want to talk to them like that. There are already stereotypes and wondering, why does a male want to work with children. Negative stereotype Where I am teaching there has been legislation that has passed that has banned the teaching of anything that makes white people feel inferior. Threats to job security I am mostly interested in teaching Black and brown children because of the lack of teachers who look like them. I want to expose them to having a teacher that looks like them. Supporting Black students Rest is important you are not your best if you are not rested. Self-care 71 A codebook was created to track all the codes identified through the analysis of transcripts. Once all transcripts were coded, a second pass of open coding was conducted to ensure all codes had been identified and assigned. The final codebook consisted of 57 codes with 322 code occurrences. Table 3 details the frequency of codes. The most common codes included purpose-make a difference-higher calling (f =18), unheard/excluded/prove myself (f = 17), effects of COVID (f = 14), and heavy workloads and low respect/prestige (f =12). Less common codes included benefits are important to me, desires for students to succeed, emotional safety, faculty predominantly White woman, high demand/many vacancies, safety concerns, student safety is priority, and push back against stereotypes (f = 2). Table 3 Code Frequency Code purpose - make a difference - higher calling Unheard/excluded/prove myself Effects of COVID heavy workloads low respect/prestige low pay challenges working in female dominated field disciplinarian DE&I I feel heard/my opinion is valued expected to do everything/taken for granted family members are educators provide for my family salary is important underrepresentation of Black men I don't feel unsafe good job security passionate poor work/life balance racism/discrimination special education f 18 17 14 12 12 10 9 9 8 7 7 7 7 7 7 6 6 6 6 6 6 72 support Black students support from family/friends works two jobs how to recruit more Black males issues with White women microaggression political challenges reason for becoming elementary teacher White cultural norms can't speak freely entry requirements fear of being misperceived good work-life balance has considered leaving the profession improve salary and benefits my skills are not fully used pipeline reasons for Black male turnover relationships with students self-care threats to job security authenticity difficult to recruit Black male teachers fear of being sexual accusations moderate job security my personal inspiration negative stereotype school shootings benefits are important to me desires for students to succeed emotional safety concerns faculty is predominantly White women high demand/many vacancies safety concerns student safety is priority Push back against stereotypes 6 6 6 5 5 5 5 5 4 4 4 4 4 4 4 4 4 4 4 4 4 3 3 3 3 3 3 3 2 2 2 2 2 2 2 2 The next step of the analysis was axial coding. Axial coding involved identifying relationships between the codes and then grouping them accordingly. The codes were arranged into themes and subthemes. Though the axial coding process, 7 themes and 10 subthemes were identified. The themes included physiological needs, focus on salary and 73 benefits, safety needs pertain to job security, physical safety, and emotional security, sense of belonging is often a struggle, esteem is often low, self-actualization manifests as a strong desire to make a difference, and COVID-19 influences teachers experiences. The subthemes included job security, safety, I feel a sense of belonging, outsider status, issues related to race and gender, esteem is fostered, do not feel valued, feel overworked and taken advantage of, turnover, and recruitment. Table 4 highlights the alignment of themes, subthemes, and codes. Table 4 Themes/Subthemes/Codes Themes Subthemes Physiological needs focus on salary and benefits Safety needs pertain to job security, physical safety, and emotional security Job security Safety Sense of belonging is often a struggle I feel a sense of belonging Outsider status Codes Provide for my family Salary is important Low pay Works two jobs Improve salary and benefits Benefits are important to me High demand/many vacancies Moderate job security Fear of sexual accusations Threats to job security Fear of being misperceived Good job security Safety concerns Student safety is priority School shootings I dont feel unsafe Emotional safety concerns Support from family/friends Family members are educators Relationships with students Underrepresentation of Black men Faculty is predominantly White women White cultural norms Authenticity 74 Issues related to race and gender Esteem is often low Esteem is fostered Dont feel valued Feel overworked and taken advantage of Self-actualization manifests as a strong desire to make a difference COVID-19 influenced teachers experiences Turnover and Turnover recruitment challenges for Black men in Recruitment elementary education Racism/discrimination Challenges working in female dominated field Negative stereotype Issues with White women Microaggression DE&I Political challenges Good work-life balance I feel heard/my opinion is valued Unheard/excluded/prove myself Low respect/prestige Cant speak freely My skills are not fully used Heavy workloads Disciplinarian Expected to do everything/taken for granted Poor work/life balance Purpose make a difference -higher calling Passionate Reasons for becoming elementary teacher My personal inspiration Support Black students Desires for students to succeed Special education Self-care Effects of COVID Reasons for Black male turnover Has considered leaving the profession Difficult to recruit Black male teachers Pipeline How to recruit more black males Entry requirements Finally, a thematic map was developed to create a visual that represented the relationships between the themes and the subthemes (Figure 1). 75 Figure 1 Thematic Map Physiological needs focus on salary and benefits Sense of belonging is often a struggle Outsider status Selfactualization manifests as a strong desire to make a difference Turnover Job security Safety needs pertain to job security, physical safety, and emotional security Safety I feel a sense of belonging Issues related to gender and race Dont feel valued Turnover and recruitment challenges for Black men in elementary education Recruitment Esteem is fostered Esteem is often low Feel overworked and taken advantage of COVID-19 influenced teachers experiences 76 Results of the Analysis Physiological Needs Focus on Salary and Benefits The first main theme to emerge focused on participants physiological needs, which was in direct alignment with research question 1. This theme illustrated ways participants viewed salary and benefits as essential to fulfilling their physiological needs. The importance of salary was mentioned by all participants. For example, when asked about the importance of pay, Ralph replied, Absolutely, important components, just like any other profession, we are in a culture where money says a lot about what you do. In response to the same question, Eugene shared, Salary was a huge, huge thing to me, while Julian admitted salary was extremely important. Horace described the importance of salary and benefits, in terms of being a single father, Going from two incomes to one in the household I want to make sure I can take care of needs and for benefits that my daughter and me can get regular health checkups. Analysis of the participants response generated six codes which included: providing for their family, salary is important, low pay, works two jobs, improve salary/benefits, and benefits are important there were no subthemes that emerged from the theme of physiological needs. Safety Needs Pertain to Job Security, Physical Safety, and Emotional Security The second main theme to emerge focused on participants safety needs, which was in direct alignment with research question 2. This theme illustrated ways participants viewed job security, their physical safety, and their emotional safety as essential to fulfilling their safety needs. Job security was mentioned by all participants whether they 77 described it as having good job security or things they felt threatened their job security. When discussing safety, the participants rarely mentioned much about their own safety, focusing instead on the safety of their students. Job Security The first main subtheme that emerged when discussing safety needs was that of job security. Job security was mentioned by all participants whether they described it as having good job security or things they felt could threaten their job security. For example, while describing job security, Eugene replied, We do have the benefits of being Black males where they are not many at the elementary level that we can go to different districts and find a job. In agreement with Eugene about not having a fear of finding a job, Julian shared, As an elementary teacher, I feel very secure, that if I had to teach somewhere else at the end of the year, I know 100% that I could land a job. Augusta had a different take on job security, explain that certain politics are threatened the jobs of many teachers at his school. Augusta explained, Where I am teaching, we have legislation that has passed that he opened legal pathways for parents to directly sue teachers, which makes it as a Black male especially at the elementary level of walking through a minefield. Safety The second main subtheme that emerged when discussing safety needs was safety, including personal safety, emotional safety, and physical safety. The importance of safety was highlighted by all the participants, but they focused more on the safety of their students. For example, when asked about his safety, Horace responded, Ive never thought about my personal safety. I have always felt that as a teacher my role was focused on making my students a number one priority. In response to the same question, 78 Wes replied, I always want to make sure my students are ok, even if in a dire situation I always will put my students first and make sure they are alright. Julian responded differently, Sometimes I feel that they are not has high as they would be if teaching high school. In terms of school shootings and gun violence. The mentality of putting their students first, coupled with demands placed on Black male elementary, could cause some threats to emotional safety. Herman, mentioned in his response, Feeling protected or safe emotionally often within public education just is not there. Sense of Belonging is Often a Struggle The third main theme to emerge focused on participants sense of belonging, which was in direct alignment with research question 3. This theme illustrated ways participants viewed their place in the education profession, specifically at the elementary level, as essential to fulfilling their sense of belonging needs. Many of the Black male elementary teacher participants said they felt sense of belonging was often a struggle for them in their roles. The theme had three main subthemes that emerged, including I feel a sense of belonging, outsider status, and issues related to race and gender. I Feel a Sense of Belonging The first main subtheme that emerged when discussing sense of belonging was that Black male elementary teacher participants felt a sense of belonging. When asked about his sense of belonging, Wes replied, They are trying to make me feel comfortable and work with me to ensure I am prepared for my class and when I have concerns, I feel as though they hear me out. Responding to the same question, Ralph stated, The students knew from a previous role and welcomed me, so the teachers and the administrators followed. Augusta responded, There are opportunities where I was 79 asked to be on certain committees or work on different projects and that was appreciated and welcomed. A sense of belonging extended beyond the school walls for Julian. When asked about the support he received from family members, Julian responded, My mother taught, and my grandmother taught, and I have other family members who taught as well. In response to the same questions, Herman replied, I come from a family of educators. I was trained by mother and her mother trained her. Wes admitted that while he came from a family of educators, they taught at the middle school and high school levels. When he told them he would be an elementary teacher, he said they were shocked, but supported his decision. Outsider Status The second main subtheme that emerged when discussing sense of belonging was that Black male elementary teacher participants often felt like outsiders. The outsider status was felt because women dominated the teaching profession especially at the elementary level. Five of the participants mentioned outsider status when referencing the underrepresented number of Black male elementary teachers. Horace mentioned, I think being a Black male in the field of education is rare, but then on top of that, if you have training in special education. Herman agreed by saying, we do not have a lot of men in the space. Eugene mentioned that when he graduated from his program before teaching, he was the only Black male graduating with a degree in elementary education. Ralph referred to Black male elementary teachers as unicorns. Herman also mentioned White cultural norms when referencing his feelings of being an outsider. He said, I think the school system, especially in this country is designed for Black and Brown people to not 80 succeed. Augusta responded similarly by saying, Most schools are run on norms of the white middle class. Issues Related to Race and Gender The third main subtheme that emerged when discussing sense of belonging had to do with issues the Black male elementary participants dealt with in terms of race and gender. Augusta mentioned two situations in which he experienced racism and discrimination. The first was when he was hired at a school, the White lady in the front office told him, I am not sure how this is going to go with you working here. At the same school, he mentioned that he had got to school early to get some work done and he was mistaken for the custodian by an older White lady. Julian responded to the question about working in a field dominated by White woman by saying, I never had an issue with working with Black women or White men, but for some reason there has always been an issue with working with White women. He went on to share that he felt the White women he worked with lacked proper communication skills and lacked selfawareness. Esteem is Often Low The fourth main theme to emerge focused on participants esteem needs, which was in direct alignment with research question 4. This theme illustrated ways participants viewed their esteem needs as Black male elementary teachers. The esteem for the Black male elementary teacher participants was often low. There were three subthemes that emerged from the participants, including esteem is fostered, they do not feel valued, and they feel overworked and taken advantage of. 81 Esteem is Fostered The first main subtheme that emerged when discussing esteem needs of the Black male elementary teacher participants was around their esteem is fostered. When talking about the balance he has, Horace, stated, Right now I feel it is balanced. I can get my work done and not have to take work home. Augusta replied similarly by saying, I do not check emails at home. I do not stay at work extremely late unless my boys have afterschool clubs. Wes talked about how important it was to leave work at work: With work-life balance, the first thing is to keep everything at work as much as possible whenever at home, it is like my sanctuary. Do Not Feel Valued The second main subtheme that emerged when discussing esteem needs of the Black male elementary teacher participant was the lack of value they felt. The lack of feeling valued was mentioned by many of the participants. For example, when asked about the lack of value felt, Eugene replied, We always must prove ourselves, and that gets old fast. Why do we have to prove ourselves [when] we are already at the table? In response to the same question, Wes shared, I do feel I get overlooked by others, even newer teacher who someone sees one good thing in their room one day and they get recognized where I do not get recognized. Julian shared about not feeling valued when it was time to collaborate with colleagues, sharing that his ideas were often overlooked and ignored: If I do something on my team, or come up with great idea, it is not necessarily heralded or regarded in the same way as a white woman coming up with something that was invented 1,000 years ago. In response to a question about the prestige of the 82 profession, Horace replied, Teaching is not respected to the degree that it probably should [be]. When [I] think about other fields, it is not taken seriously. Feel Overworked and Taken Advantage of The third main subtheme that emerged when discussing esteem needs for the Black male elementary teacher participant was focused on them feeling overworked and taken advantage of. Many of the participants shared feelings of being looked at as disciplinarians. Ralph discussed being pigeonholed into discipline because he was a Black male in the school. I get put in a box, I became a disciplinarian and I get all the students who get in trouble. Responding to the same questions, Horace stated, As a Black male you automatically became a disciplinarian. You are not seen as a teacher or educator or as someone who possess the knowledge to educate students. When asked about the heavy workload, put on Black male teachers the participants had strong opinions. The participants shared their feelings on the heavy workload. Wes stated, As teachers, we are not just teaching, we have to be the parents, and deal with whatever comes up that is not teaching. Augusta also shared feelings of the heavy workload, The workload is intense. We get a 45-minute prep, but that time gets taken up by parent phone calls, case conference meetings, and other things the administrations need from us. When describing times they were taken advantage of, Julian replied, They want us to do all the work. Even when they do the bare minimum, they get exhausted by that, and I am left picking up the slack with things like helping with behavior issues and getting the class quiet. 83 Self-Actualization Manifests as a Strong Desire to Make a Difference The fifth main theme to emerge focused on participants self-actualization, which was in direct alignment with research question 5. This theme illustrated ways participants viewed their desire to make a difference as essential to fulfilling their self-actualization needs. This importance of making a difference was mentioned by all participants. For example, when asked about his purpose, Eugene replied, We want to show that teaching, especially at the elementary level, does not have to be dominated by women. In response to the same question, Wes shared, I did not get into education for the money, I got into to make a difference in my community and the lives of my students. Augusta replied in one word for why he became an elementary teacher: Passionate. When asked about his personal inspiration for teaching at the elementary level, Herman shared, I think it can be legacy, and something that is family inspired. Responding to the same question, Julian replied, I am emotionally connected to the students, and I want to enrich them and see them grow into something positive when they grow up. Analysis of the participants response generated six codes which included: purpose, passionate, personal inspiration, supports Black students, desire for students to succeed, and self-care there were no subthemes that emerged from the theme of selfactualization. COVID-19 Influenced Teachers Experiences The sixth main theme to emerge focused on participants experience and the influence of COVID-19, which was in direct alignment with research question 6. This theme illustrated ways participants viewed their experiences during COVID-19. All the Black male elementary teachers were in the classroom during the COVID-19 pandemic. 84 For example, when asked about the influence of COVID-19, Eugene replied, In my personal and professional life, it made me be more intentional. In response to the same question, Julian shared, I am not the same teacher I was before in terms of disposition they actually feel different to teach and I am much more tolerate than I as before. Ralph similarly replied to the questions by saying, What COVID-19 did was a shine the light on the glaring inequities in our schools and our country. Herman shared what he believed many people realized during the pandemic about teachers, If we saw anything during the pandemic, we saw how important teachers are, especially in the time of crisis. Augusta shared a similar sentiment as Herman, When COVID-19 came, everyone seemed to value teachers a lot more than they did before COVID-19. Turnover and Recruitment Challenges for Black Men in Elementary Education The seventh and final main theme to emerge focused on what participants felt regarding the turnover and the recruitment challenges for getting more Black men at the elementary level. This theme was aligned to questions asked throughout the interview on turnover and recruitment challenges. All the Black male elementary teacher participants responded to questions on recruiting more Black males to the elementary level. Turnover The first main subtheme that emerged when discussing turnover and recruitment challenges centered on the turnover of Black male elementary teachers. The Black male elementary teacher participants shared some strong views on the turnover of Black male elementary teachers. For example, when asked about the reason for Black male elementary teacher turnover, Horace replied, The Black males leave the profession, because of the lack of recognition, being overworked, stressed out, and not seeing the 85 change in the profession that they came for. Responding to the same question about turnover, Herman replied, I feel there are two reasons. The lack of value of Black male teachers in the system, and as Black male teachers we are not just policing children, but we become the police to the children. Julian discussed the emotional toll that happens that caused Black male teacher turnover, I believe to make a decision that is emotionally rooted and then not have that fulfilled caused an immediate flight or fight emotion and it usually means for the Black male teacher to flight and leave the profession. Two of the participants shared powerful sentiments on why they considered leaving the profession. Augusta shared, I started to become unhappy, and if figured if I am not going to be happy then I might as well make more. I then began to apply for five or six different jobs. Ralph similarly mentioned, Many teachers were doing the best they could, but it just was not enough. It was enough for the kids in the school, and it just became an exercise of frustration day after day. Recruitment The second main subtheme that emerged when discussing turnover and recruitment of Black male elementary teachers was focused on recruitment, specifically the challenges with recruitment. The Black male elementary teachers shared why they felt it was difficult to recruit Black male teachers. For example, when asked about difficulties with recruitment, Augusta replied, There are many external pressures to not go into teaching. As a teacher starting off, you make less than $50,000, but in engineering and medicine you come out after your degree making more sometimes even double what you would make as a teacher starting off. When asked about how to increase the pipeline of Black male elementary teachers coming through, Horace replied, A lot of 86 Black males did not have a positive experience in elementary school when they grew up. That will deter them from wanting to go into the profession. In response to the same question about increasing the pipeline, Eugene stated, We are going to have to groom them. We must think about growing our own. Ralph stated, There are going to have to be more avenues and more ways to spark the interest of Black males wanting to become elementary school teachers. When asked about what specifically could be done to recruit more Black males to the elementary level, Wes replied, We must bring more Black males to our elementary classrooms. We must bring them in to shadow or volunteer to read a book to the kids and give them a chance to interact with the elementary students. Responding to the same question, Herman stated, We need to contract organizations that are led by Black men who focus and specialize in recruiting Black men. The Black men must see that they are not alone that there are inspirations they can follow behind. Augusta responded with statement on requirements, There are a lot of requirements. There are a lot of tests. We should probably think about teacher licensure, there is a lot of work that goes into becoming a teacher and maintaining teacher status. Summary In chapter 4, the researcher presented findings from the qualitative study that explored the lived experience of seven Black male elementary teachers while using the framework of Maslows hierarchy of needs. In chapter 4, readers will find responses from the participants related to the research questions of the study. Chapter 4 began with participant descriptions, data analysis, examples of open coding, code frequency table, a table of themes/subthemes/codes, a thematic map, and results from analysis. The 87 interviews of the participant captured how their physiological, safety, esteem, sense of belonging, and self-actualization needs were met. Additionally, the interviews captured the experiences of the Black male elementary teachers during COVID-19, how they felt about the recruitment challenges, and ways to combat high turnover among Black male teachers at the elementary level. The research findings included seven themes which were: physiological needs focus on salary and benefits; safety needs pertain to job security, physical, safety, and emotional security; sense of belonging is often a struggle; esteem is often low; selfactualization manifest as a strong desire to make a difference; COVID-19 influences teachers experience; and turnover and recruitment challenges for Black men in elementary education. The ten subthemes derived from the data were: job security; safety; I feel a sense of belonging; outsider status; issues related to race and gender; esteem is fostered; do not feel valued; feel overworked and taken advantage of; turnover; and recruitment. The findings of the study show showed that barriers had an impact on the recruitment and were perceived as causes of turnover among Black male teachers at the elementary level. All the participants mentioned the importance of salary and benefits as part of their experience. While the participants shared that overall, they had the support of family members, they did also feel undervalued and overworked as elementary teachers. One participant shared that the predominantly White female culture was a barrier that could cause issues for Black male elementary teachers in getting their voice heard. Three participants believed they were primarily thought of by their schools as disciplinarians and not individuals who could lead in the education of children. For example, one 88 participant shared that he was used to policing children who were misbehaving, and his class roster was full of students who the administration deemed as behavior concerns. In the next chapter, the researcher will present a summary of the study, highlight implications, and provide potential recommendations for future research. 89 CHAPTER 5 DISCUSSION Introduction The purpose of this qualitative study was to examine the lived experiences of Black male teachers to understand why they decided to teach at the elementary level. The framework was provided by Maslows (1954) hierarchy of needs. The study was anchored by a literature review that explored that many roles and titles placed on Black males who decided to not only teach at the elementary, but all men who decide to dedicate their lives to teaching. The importance this study was stated by Brown (2012) as the voices and lived experiences of Black male teachers are often left out of the research. It was important in this study to get the voices of current Black male teachers and not Black male teachers who had already left the profession. The stories of the Black male elementary teachers added to the body of research of Black male teachers, just as the scholars who had researched before including, Bristol, Brockenbrough, Brown, Gordan, and Mitchell. In this study, the stories and insights from the Black male elementary teachers revealed their experiences teaching at the elementary level. Additionally, those experiences coincided with a global pandemic that halted not just the school system, but the entire country. Across this study, the Black male teachers shared the driving force behind the work they did, the challenges of unwanted pressures, issues with being the super minority, thoughts on factors that cause Black males to leave the teaching profession, and their own struggles with staying in the profession. Although they did not speak of it directly, participants often seemed to carry burdens related to the impact of 90 COVID-19, their drive to make a difference, and the need to do something that felt purposeful and rewarding. This chapter begins with a summary of the study, which provides an overview description of the problem, purpose statement, research questions, review of the study design, participant selection, data collection, data analysis, and a summary of the major findings. This chapter includes a conclusion section that focuses on an overview and analysis of the findings. In addition, implication for practitioners are provided. The recommendations section highlights opportunities for future research on the topic of Black male elementary teachers. The last section includes the researchers final remarks and perspectives. Summary of Major Findings This studys theoretical framework was Maslows (1954) hierarchy of needs. These needs guided the research and interview questions. Additionally, the researcher considered participants experiences within the context of the COVID-19 pandemic. Research Question 1 The first research question focused on participants physiological needs. The theme that emerged from this research question highlighted the importance of salary and benefits. Overall, salary was an important component for the Black male elementary teacher participants. Each of them spoke about salary, while benefits were not mentioned as often. Those who spoke more about benefits were the Black male elementary teacher participants who were married or had children. Nelson (2002) highlighted how low teaching salary, coupled with the rising costs of college, are primary reasons why Black males do not become teachers. 91 Research Question 2 Research question two was focused on participants safety needs. The theme that emerged from this research question focused safety needs as they pertained to job security, physical safety, and emotional safety. Two subthemes emerged from the research question, which focused on job security and safety. The participants shared that they felt as though they had good job security due to the low number of Black male teachers, especially at the elementary level. Participants worried more about the physical safety of their students than of themselves. The threat of school shootings was on the mind of few of the participants. The participants believed their job was protect their students. For many years, Black male educators have been the linchpin for their communities (Smith, 2021). Research Question 3 Research question three was focused on participants belonging needs. The theme that emerged from this research question, focused on a sense of belonging being a struggle. Three subthemes emerged, including I feel a sense of belonging, outsider status, and issues related to gender and race. The Black male elementary teacher participants shared that belonging as teachers at the elementary level was a struggle. One participant said he felt a sense of belonging because his colleagues made him feel comfortable. The majority, however, expressed what was termed in the study as outsider status. Research Question 4 Research question four was focused on participants self-esteem needs. The theme that emerged from this research question revealed esteem was often low. The three subthemes that emerged were esteem is fostered, do not feel valued, and feel overworked 92 and taken advantage of. In some cases, study participants shared that esteem was fostered because they created a sense of balance in their lives, leaving work at work. Other participants shared their struggles with esteem and how they did not feel valued, or they felt as though they were taken advantage of. Many participants said they were used primarily for discipline instead of instructional purposes. Casteel (1998) highlighted this notion, explaining that many schools give Black male teachers discipline duties instead of duties related to mentoring or instruction. Bristol and Mentor (2018) expanded on this, highlighting how Black men felt they were expected to be effective in crowd control and redirecting behavior. Research Question 5 Research question five was focused on participants self-actualization needs. The theme that emerged from this research question focused on how self-actualization manifested as a strong desire to make a difference. The Black male elementary teacher participants expressed a desire to make a difference. There was a strong passion for teaching at the elementary level. Participants expressed both inspiration from family who were teachers and for ensuring their students can be successful. They all want to make a difference. Holmes (2022) similarly found that Black men expressed a strong desire to teach to make a difference in the lives of their students. Research Question 6 Research question six was focused on the experience teaching during the COVID19 pandemic. The theme that emerged for this research question was focused on how COVID-19 influenced teachers experiences. COVID-19 was such a difficult time for all educators. The Black male teachers were mixed in their responses about the impact of 93 COVID-19. Some of the participants explained that COVID-19 provided them with more motivation because of the inequalities that were made increasingly evident during the pandemic, as many students were out of school and lacked the resources they needed to learn. One participant expressed how his teaching style changed after COVID-19, as he was very strict before but became more tolerate afterwards. While COVID-19 did not cause of any of the participants to leave the profession, each of them did ask themselves the question whether their love for their students and teaching was worth the strain and pressure they felt during COVID-19. Another theme emerged from questions asked in each research question and that was turnover, and recruitment challenged for Black men in elementary education. The subthemes that emerged focused on turnover and recruitment. We know that retention is a concern for Black male teachers, as the Black teacher workforce has decreased in roughly nine major cities over the last decade (Griffin & Tackie, 2017). The Black male elementary teacher participants shared insights and suggestions on what can be done to both slow down the turnover rate and to recruit more Black male teachers to the profession. Recruitment and retention will likely remain a topic of discussion for years to come, as the Black male elementary teacher participants in this study explained how hard it was to teach at the elementary level. Black and Rice (2020) noted that being Black and male in the American education system carries with it a slew of social implications. Differences in Participants Background Each participant in the study shared two distinct identifications markers: they were Black and teachers. Those distinct markers would have one believe their experiences were the same. In some respects, they were, but in others, they were not. Of 94 the seven participants, three were from states in the Midwest, while others represented states from the South. In some respects, the experiences of those from the South differed from those in the Midwest. The four participants from the South highlighted the importance of school safety with the recent school shootings across the country. They saw their roles as educators to include a responsibility to protect the physical safety of their students. The three participants from Midwest were all fathers who discussed how fatherhood played a role in the type of teachers they were and their obligations to educate other children as if they were their own. School types were another way the participants experiences were different. Two of the seven participants taught outside a charter school, either a traditional public school or a rural school. In their interviews, these participants shared how a community or political pressure made their jobs more difficult. The five charter teachers shared a commonality regarding the many hats they wear in their school outside of just being a teacher. It was almost expected that they do more than teach. Each participants journey to the classroom was different. Their experience growing up was not the only thing that made their pathway to the classroom different, but also their certification. The seven participants accounted for four different pathways. Two participants were traditionally trained, meaning their undergrad degree was in teaching. They each experienced the student teaching experience and got into teaching at an early age without any other full-time jobs. The two participants whose pathway to certification included a different route worked jobs in education, but outside of K-12 education. The two teachers completed transition programs but worked under mentor teachers for at least one year before taking classrooms over on their own, full-time. 95 Implications There is support from both the state and federal level to increase the number of Black male teachers in schools across our country. Research exists on ways schools and districts can recruit and retain more Black male teachers. As highlighted in Chapters 1 and 2 of this study, schools need to place higher value on the skills and contributions Black male teachers make beyond those of roles models (Brown, 2012). Lewis (2006) suggested that Black males represented an endangered species in the profession due to the amount leaving and the low number entering the profession. Based on findings from this study, a few practical suggestions may be implemented: 1. School districts should focus on the physiological needs of Black male teachers. One way this can be done is by increasing teachers salaries, not just at the starting level, but at all levels of experience. 2. School districts should focus on the safety needs of Black male teachers. As shared by the participants in this study, Black males believe in the safety of their students often more than their own safety. Knowing this will allow school districts to have a better understanding of Black male teachers. 3. Schools and school districts should focus on the sense of belonging for Black male teachers. There should be an emphasis on recruiting Black men at the elementary level, to offset gendered stereotypes of male teachers at the elementary level. 4. School districts should focus on the self-esteem needs of Black male teachers by creating pathways in the instructional lane for Black men to participate, rather than relegating them to disciplinarians. 96 5. School districts should create Black male teacher affinity spaces for the Black male teachers to share stories and connect with one another. Recommendations This study highlighted the perspectives of seven Black male elementary teachers lived experiences and motivations to teach at the elementary level. Further research on the lived experiences of Black male elementary teachers who both stay and leave the profession is highly recommended. To gain a different perspective and gather additional data, the following are suggested studies for future research: 1. Interview Black male teachers in teacher preparation programs who are studying to teach at the elementary level, focusing on those in their last year; 2. Interview Black male teachers in alternative programs who decide to teach elementary instead of secondary; 3. Compare Black male teachers who began at the elementary level but moved to the secondary level; 4. Compare Black male teachers from both the elementary and secondary on reasons why they both stayed and left the profession; 5. Interview Black male elementary teachers who spent their entire careers at the elementary level and retired. In an effort to continue the conversation around Black male teachers, specifically at the elementary level, it will be important to include the work of Gloria Ladson-Billings. Gloria Ladson-Billings pioneering work on culturally relevant pedagogy (CRP) and the intersection with critical consciousness provides a valuable framework for understanding the role of Black male teachers and their connections to the communities they serve. As 97 Ladson-Billings (1995) highlighted, CRP emphasizes incorporating students' cultural backgrounds and experiences into the curriculum to enhance their engagement and academic achievement. The approach recognizes the unique cultural context of Black students, including those taught by Black male teachers. Gloria Ladson-Billings work accentuates the importance of fostering critical consciousness among Black male teachers to address issues of racial inequality within the educational system (Ladson-Billings, 2006). Gloria Ladson-Billings argues that Black male teachers possess a unique perspective that can challenge and disrupt existing educational power structures. She contends that by developing a critical consciousness, these educators can become advocates for equity and social justice within the classroom (Ladson-Billings, 1995). In her research, Ladson-Billings highlights the experiences of Black male teachers who have developed critical consciousness. While this study did not discuss critical consciousness, future research would benefit from her work as it highlights how teachers often engage in culturally relevant and responsive pedagogy, creating inclusive learning environments that empower Black students and challenge stereotypes (Ladson-Billings, 2014). Ladson-Billings also emphasizes the need for teacher preparation programs and professional development opportunities to support the development of critical consciousness among Black male teachers (Ladson-Billings, 2009). The scholarship of Gloria Ladson-Billings' specifically on critical consciousness and its relevance to Black male teachers, highlights the importance of empowering Black male teachers to challenge inequities within the education system. Black male teachers, who often share similar cultural backgrounds and life experiences with their students, are well-positioned to engage in culturally responsive practices that foster critical thinking 98 and awareness of social inequities. The advancement of the body of research around Black male elementary teachers would contribute significantly by including the work of Gloria Ladson-Billings. Gloria Ladson-Billings highlights the importance of community connections in developing critical consciousness (Ladson-Billings, 2006). Black male teachers who maintain strong ties to their communities can serve as liaisons between the school and their broader community. Conclusion The low number of Black male teachers entering the profession is concerning, as is the high number of Black male teachers leaving the profession. The research mentioned in this study and previous studies highlighted how Black male teachers benefit all students, especially Black students. The participants in this study not only shared their experiences as elementary teachers, but also provided reasons why Black men enter, stay in, and leave the profession. Their stories and the stories of other Black male teachers should be considered in ways leaders work to increase recruitment and retention of these individuals. The participants in this study shared first-hand accounts of their experiences as elementary teachers; those experiences highlighted the importance of considering how Black males are treated, as teachers. While the participants mentioned that salary and benefits were important to them, the low salary they were paid had not caused them to leave profession. While the participants mentioned different situations in which their voices were not valued, they did not leave the profession. While the participants shared examples of being overworked or 99 only looked at as disciplinarians, they did not leave the profession. Despite being given multiple reasons to leave the profession, these Black male elementary teacher participants stayed. They stayed because their passion and drive ran deep. The one thing that was obvious is the Black men in this study were doing this work not for themselves, but for their students. Participants wanted to be looked at as teachers who could lead students to academic achievement and serve as positive role models. Whether motivated by their own experiences growing up in school, the connection to the family ties of teaching, or making a difference, these Black men were clearly more than security guards in schools. They were the brains of their schools. Final Remarks The challenges faced by Black men in this time are more serious than any other challenges they have faced since the beginning of human time (Akbar, 2016). Even with the ability to do something completely different with their lives that will bring them more money, more recognition, and more praise, the Black men in this study each decided to teach and teach at the elementary level. They also each had made commitments to educating the future and putting students on paths to find their own greatness. After reading their stories and hearing their experiences, there was no doubt that all seven of the participants in this study loved what they did for a living. They saw teaching as a calling and a higher purpose. That feeling, along with their passion and desire to spark change, was what kept them going and allowed them to do everything that came with being a Black male teaching at the elementary level. These Black men carried a burden and wore many hats in their schools, some titles they embraced and others that were 100 placed on them. They carried the burden proudly and continued to do their part for the students they served. While the search continues to find the silver bullet or magic potion to increase the number of Black male teachers, studies like this are important to learning about the experiences of Black male teachers, especially those at the elementary level. It is my hope that we continue to study the experiences to lend a voice to the men who are the stalwarts in their schools and communities. The struggle with recruiting and retaining Black male teachers is one that begins as early as the school experience of Black boys. 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Teach For America. https://www.teachforamerica.org/stories/what-it-takes-to-retain-blackmale-teachers 122 APPENDIX A RECRUITMENT EMAIL Dear [Insert Name of Recipient] My name is David McGuire, a doctoral candidate at Marian University in the Klipsch Educators College. I am recruiting Black male elementary teacher participants for an interview style qualitative student on their lived experiences and journey to the profession. I am writing to ask if you would agree to send my call to participants to all the Black male elementary teachers in your network. The requirements for the study are listed below. Please feel free to share with anyone who may be interested and meets the criteria. I have attached a flyer as well to the email for reference. To participate, participants must meet each of the following: 1. Identify as an African American 2. Identify as male 3. Teach at the elementary level (K-6) 4. Teach in a content area (ELA, Math, Science, Social Studies) 5. At least one year of teaching experience All interested participants can complete a short survey of interest here: https://forms.office.com/Pages/ResponsePage.aspx?id=ojUh6k3AqkGBPnCddSlLSMmR McnwiUBDoyWR1p0_DdVURTgyM1hLTkcxRkJUWjZaWVFVUUJFR0FBMC4u 123 Interested participants or anyone who has any questions can email me directly at dmcguire333@marian.edu. Thank you for your time. 124 APPENDIX B RECRUITMENT FLYER 125 APPENDIX C RECRUITMENT NOTE I am a doctoral candidate at Marian University studying the lived experiences of Black male elementary teachers. For my dissertation research, I will be recruiting Black male elementary teacher participants for an interview-based study of experiences through life and the teaching profession. If interested in participating in an interview, please complete the survey. https://forms.office.com/Pages/ResponsePage.aspx?id=ojUh6k3AqkGBPnCddSlLSMmR McnwiUBDoyWR1p0_DdVURTgyM1hLTkcxRkJUWjZaWVFVUUJFR0FBMC4u Here are the recruitments to participate. You must be all the following: 1. Identify as an African American 2. Identify as male 3. Teach at the elementary level (K-6) 4. Teach in a content area (ELA, Math, Science, Social Studies) 5. At least one year of teaching experience I hope you will be able to help with my research. Please feel free to share with others who you think may be interested and meets all the criteria. Any questions or concerns about the recruitments, please free to email me at dmcguire333@marian.edu. 126 APPENDIX D PARTICIPANT RECRUITMENT SURVEY Link: https://forms.office.com/Pages/ResponsePage.aspx?id=ojUh6k3AqkGBPnCddSlLSMmR McnwiUBDoyWR1p0_DdVURTgyM1hLTkcxRkJUWjZaWVFVUUJFR0FBMC4u 127 APPENDIX E CONSENT EMAIL TO POTENTIAL PARTICIPANTS Dear [Participant Name], Thank you for completing the study participant survey form. This email is to confirm that you have been selected to participate in the study. Please complete the attached demographic questionnaire. The information will be reviewed prior to the scheduled interview. I ask that you take some time to read all the information below regarding participation in the research study. Voluntary Nature of Study Participation in this study is voluntary. There will be no negative consequence for participating or not. If you agree to participate and later decide to discontinue your participation, you may do so at any time. Risks and Benefits of the Study As it stands there will be no risks in your participation in this study. Your participation in this research study will not impact your general safety and wellbeing. There are no direct benefits to the participants. The benefits to the broader community could be the changing of the perception around the importance of having a Black male teacher at the elementary level. Payment There is no payment or gifts (monetary or otherwise) for your participation. 128 Privacy Information shared will be kept confidential; your name or any personal information that can identify you in the study reports will not be included. The researcher will not use this information for any purposes outside of this research project. The names of the participants will be coded using the pseudonym you select in the questionnaire to protect the identity of the participants. Additionally, the audio recording will be transcribed, and you will be allowed to review the interview transcripts before the material is coded and reviewed for themes. Lastly, the researcher will keep all materials used for the interview and study locked away where only the researcher will have access to the information. The audio recordings will be destroyed after the completion of the study. All data will be kept securely, locked away by the researcher David McGuire, in compliance to the Marian University rules. Once you have read and you agree to all the terms send me three dates and times that work best for you for the interview. The interviews will last between 30-45 minutes, but I am asking that give me an hour of your time. Consent By replying to this email with the words I Consent and your first and last name in the subject line, you are agreeing to participating in this study. For your own record keeping, please print and or save a copy of this consent form. 129 APPENDIX F DEMOGRAPHIC QUESTIONNAIRE Please complete the demographic questionnaire below. Please write or type your responses and email them back to me at dmcguire333@marian.edu. 1. Chosen pseudonym: ____________________________________ 2. Grade level teaching: ___________________________________ 3. Type of school: (circle one that apply) Public School, Public Charter, Private School, Catholic School 4. State where you teach: ___________________________________ 5. Pathway to Teaching: (circle one that apply): Traditionally trained [attended and graduate from a school of education at four-year university], Transition to teaching program [ Teach for America, Teaching Fellows, other], Different route 6. Undergrad College Attended: (circle one that apply) Historical Black College and University, Predominately White Institution 7. Number of years in the classroom: _________________________ 8. Age Range: (circle one that apply) 22-29 30-37 38-45 46-53 45 and older Anything else youd like to share: ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ 130 APPENDIX G RESEARCH AND INTERVIEW QUESTIONS Background Questions: 1. Who is participants name. The man 2. Who is participants name The Educator Research Questions 1. How did Black males experience COVID-19 as an elementary teacher? Interview Questions 2. What physiological needs are met for the Black male teacher? 3. What safety needs are met for the Black male teacher? 4. How does the Black male teacher feel a sense of belonging? 5. What self-esteem needs are met for the Black male teacher? Describe where you were in your career when COVID-19 first impacted schools? March 2020 If you were in a teaching program or undergrad, did you ever consider switching careers? If you were currently teaching, did you ever consider leaving the profession? How does COVID-19 impact you as an elementary teacher? Describe your work life balance? Are the salary and the benefits an important component to job satisfaction? How would you describe job security as an elementary teacher? What safety concerns did you have as an elementary teacher? Personal and School Are there any challenges working in a field dominated by women? Describe how those close to you felt when you decided to work as an elementary teacher? Did you feel your race and gender make it challenging to work as a team? How would you describe the balance between the workload of a teacher and the prestige of the profession? What can be done to recruit more Black males to teach at the elementary level? Do you believe you receive equal recognized as those of another race and ethnicity? 131 6. What self-actualization needs are met for the Black male teacher? Do you feel that your skills are being used to their maximum potential as an elementary teacher? Why do you believe Black males decide to become teachers? Why do you believe Black males leave the profession? 132 APPENDIX H INTERVIEW PROTOCOL SCRIPT Introduction Thank you for taking the time out of your busy schedule to discuss your experiences as a Black male elementary teacher. You met all the criteria for participation in this study. Thank you for getting back the consent form and the demographic questionnaire. A few reminders from the consent email sent previously, your participation in this study is voluntary and that even after beginning you can at any time withdraw from participation from this study. There is no payment from this study and the confidentiality is extremely important this recorded conversation will be locked away where only the researcher has access. This virtual interview will take between 30-45 minutes but thank you for blocking out an hour of your time. Your responses will help the researcher gain perspectives on the lived experience of Black male elementary teachers and led to effort to increase the number in schools. In writing the pseudonym you selected will be used and please refrain from using names, but if you do try to use first names only. Do you have any questions before the interview begins? Interview Script Recording will begin now. {Document the day of the week, month, date, and year of the interview. Document the time the interview begins.} I have received all consent 133 and required documents. Remember please be honest in all your responses based on your own lived experience. Interview Questions RQ1: How did Black males experience COVID-19 as an elementary teacher? Interview Questions: Describe where you were in your career when COVID-19 first impacted schools? March 2020 If you were in a teaching program or undergrad, did you ever consider switching careers? If you were currently teaching, did you ever consider leaving the profession? How does COVID-19 impact you as an elementary teacher? RQ2: What physiological needs are met for the Black male teacher? Interview Questions: Describe your work life balance? Are the salary and the benefits an important component to job satisfaction? RQ3: What safety needs are met for the Black male teacher? Interview Questions: How would you describe job security as an elementary teacher? What safety concerns did you have as an elementary teacher? Personal and School? RQ4: How does the Black male teacher feel a sense of belonging? 134 Interview Questions: Are there any challenges working in a field dominated by women? Describe how those close to you felt when you decided to work as an elementary teacher? Did you feel your race and gender make it challenging to work as a team? RQ5: What self-esteem needs are met for the Black male teacher? Interview Questions: How would you describe the balance between the workload of a teacher and the prestige of the profession? What can be done to recruit more Black males to teach at the elementary level? Do you believe you receive equal recognized as those of another race and ethnicity? RQ6: What self-actualization needs are met for the Black male teacher? Interview Questions: Do you feel that your skills are being used to their maximum potential as an elementary teacher? Why do you believe Black males decide to become teachers? Why do you believe Black males leave the profession? Ending Script Thank you for your participation in this research study. Remember your responses will be kept confidential. A transcription verbatim of your responses will be sent to you 135 via email for your review, accuracy, and any feedback that you may have. Recording ending now. 136 APPENDIX I IRB APPROVAL  ...

... 22 APPENDIX A Citation Downey, A. W., Duggan, L. V., & Adam Law, J. (2021). A systematic review of Meta-analyses comparing direct laryngoscopy with videolaryngoscopy. Canadian journal of anaesthesia = Journal canadien d'anesthesie. Retrieved October 24, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7845281/ Research Design & Level of Evidence Level 1 Systematic Review Population / Sample size n=x Major Variables Instruments / Data collection Results VL, MAC DL A medical librarian conducted the search across databases Most currently published meta-analyses support a superiority of VL over DL VL, MAC DL, obesity A group of anesthesia researchers reviewed database articles Video laryngoscopes were superior to MAC DL for tracheal intubation in obese patients Hoshijima H, Denawa Y, Tominaga A, Nakamura C;Shiga T, Nagasaka H; (2018). Videolaryngoscope versus Macintosh laryngoscope for tracheal intubation in adults with obesity: A systematic review and metaanalysis. Journal of clinical anesthesia. Retrieved October 24, 2022, from https://pubmed.ncbi.nlm.nih.gov/29156438/ Level 1 Systematic Review 21 Metaanalyses were identified published between 20002022 comparing VL and MAC DL. 11 articles comparing VL and DL Karczewska, K., Bialka, S., Smereka, J., Cyran, M., Nowak-Starz, G., Chmielewski, J., Pruc, M., Wieczorek, P., Peacock, F. W., Ladny, J. R., & Szarpak, L. (2021). Efficacy and safety of video-laryngoscopy versus direct laryngoscopy for double-lumen endotracheal intubation: A systematic review and meta-analysis. MDPI. Retrieved October 24, 2022, from https://www.mdpi.com/20770383/10/23/5524/htm Level 1 Systematic Review 25 articles comparing VL and DL VL, DL Two research reviewers searched databases and reviewed 25 studies VL offers shorter intubation time, better glottis view, lower need for ELM, but comparable first time success rate Lee, J. Y., Hur, H., Park, H. Y., Jung, W. S., Kim, J., & Kwak, H. J. (2020). A comparison between McGrath Mac videolaryngoscopy and Macintosh laryngoscopy in children. Acta anaesthesiologica Scandinavica. Retrieved October 19, 2022, from https://pubmed.ncbi.nlm.nih.gov/29178126/ Level 3 Prospective Randomized Control Study 84 patients undergoing endotracheal intubation McGrath VL, MAC DL 84 patients undergoing endotracheal intubation were randomly assigned to the McGrath group or MAC DL Group McGrath VL provides better laryngeal views but similar intubation times and success rates compared to MAC DL  23 Robinson OJ, Smith AF (2017). Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation: A Cochrane Systematic Review. British journal of anaesthesia. Retrieved October 24, 2022, from https://pubmed.ncbi.nlm.nih.gov/28969318/ Systematic Review were included in the review MAC DL databases and reviewed 64 studies intubation with experienced operators but not inexperienced users, there was no difference in number of first attempts, VL improved glottis view and reduced trauma Bhattacharjee, S., Maitra, S., & Baidya, D. K. (2018). A comparison between video laryngoscopy and direct laryngoscopy for endotracheal intubation in the emergency department: A meta-analysis of randomized controlled trials. Journal of Clinical Anesthesia, 47, 21 26. https://doi.org/10.1016/j.jclinane.2018.03.006 Level 1 Systematic Review 5 randomized control trials VL, DL, emergency department This review involved 1250 patients from 5 randomized control trials VL offers no advantage over DL for intubation success. VL showed improvement in reducing esophageal intubations. Vargas, M., Servillo, G., Buonanno, P., Iacovazzo, C., Marra, A., Putensen-Himmer, G., Ehrentraut, S., Ball, L., Patroniti, N., Pelosi, P., & Putensen, C. (2021). Video vs. direct laryngoscopy for adult surgical and intensive care unit patients requiring tracheal intubation: a systematic review and meta-analysis of randomized controlled trials. European Review for Medical and Pharmacological Sciences, 25(24), 77347749. https://doi.org/10.26355/eurrev_202112_27620 Level 1 Systematic Review 97 randomized control trials evaluating 12,775 patients VL, DL Researchers identified all RCTs comparing VL to DL in Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE VL reduces risk of difficult intubation and increases intubation success in first attempt Nalubola, S., Jin, E., Drugge, E. D., Weber, G., & Abramowicz, A. E. (2022). Video Versus Direct Laryngoscopy in Novice Intubators: A Systematic Review and Meta-Analysis. Cureus, 14(9), e29578. https://doi.org/10.7759/cureus.29578 Level 1 Systematic Review 10 studies covering 1,730 intubations VL, DL Researchers searched databases for results comparing VL and DL VL showed particular improvements in results for inexperienced providers Rombey, T., Schieren, M., & Pieper, D. (2018). Video Versus Direct Laryngoscopy for Inpatient Emergency Intubation in Adults: A Systematic Review and MetaAnalysis of Randomized Controlled Trials. Deutsches rzteblatt International, 115(26), 437444. https://doi.org/10.3238/arztebl.2018.0437 Level 1 Systematic Review 8 RCT with 1796 patients VL, DL Literature search in databases MEDLINE,Embase, and CENTRAL were reviewed for studies VL decreases number of intubation attempts and esophageal intubations  Evrin, T., Szarpak, L., Katipoglu, B., Mishyna, N., Kockan, B. S., Ruetzler, K., & Schlpfer, M. (2022). Video-Assisted Versus Macintosh Direct Laryngoscopy for Intubation of Obese Patients: A Meta-Analysis of Randomized Controlled Trials. Disaster & Emergency Medicine Journal, 7(1), 3040. https://doi.org/10.5603/DEMJ.a2022.0004 24 Level 1 Systematic Review N/A VL,DL Jia Jiang, Danxu Ma, Bo Li, Yun Yue, Fushan Xue, Jiang, J., Ma, D., Li, B., Yue, Y., & Xue, F. (2017). Video laryngoscopy does not improve the intubation outcomes in emergency and critical patients - a systematic review and meta-analysis of randomized controlled trials. Critical Care, 21, 111. https://doi.org/10.1186/s13054-017-1885-9 Level 1 Systematic Review 12 RCTs with 2583 patients VL,DL Huang, H.-B., Peng, J.-M., Xu, B., Liu, G.-Y., & Du, B. (2017). Video Laryngoscopy for Endotracheal Intubation of Critically Ill Adults: A Systemic Review and Meta-Analysis. CHEST, 152(3), 510517. https://doi.org/10.1016/j.chest.2017.06.012 Ba, X. (2022). A Meta-Analysis on the Effectiveness of Video Laryngoscopy versus Laryngoscopy for Emergency Orotracheal Intubation. Journal of Healthcare Engineering, 2022, 1474298. https://doi.org/10.1155/2022/1474298 Level 1 Systematic Review 5 RCTs with 1,301 patients VL, DL Level 1 Systematic Review N/A VL,DL Scholtis, M. P. (2017). A Randomized, Blinded, Clinical Study of Injury Incidence During Endotracheal Intubation: Comparison of GlideScope Video Laryngoscopy and Direct Laryngoscopy. AANA Journal, 85(6), 445451. Level 2 RCT 155 patients undergoing surgery VL, DL Researchers searched databases SCOPUS, MEDLINE, CINAHL for results comparing VL to DL VL is superior to DL due to improved first attempt success, glottis visibility, and lower injuries. Researchers searched Cochrane Central Register of Controlled Trials, PubMed, EMbase, and Scopus databases and 12 RCTs with 2583 patients were reviewed Researchers searched PubMed, Embase, and Cochrane database and reviewed 5 RCTs with 1,301 patients Researchers searched MEDLINE, CENTRAL, EMBASE VL does not improve intubation outcomes 155 patients were randomized to either Glidescope VL or DL groups There was no statistically significant difference in injury between VL and DL VL did not improve first attempt success No significant efficiency with VL compared to DL  Davies, M., & Hodzovic, I. (2021). Videolaryngoscopy Post covid-19. Trends in Anaesthesia & Critical Care. Retrieved January 23, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC513920/ 25 Descriptive study 29 articles Covid19, video laryngscopy 29 articles were reviewed video laryngoscopy use offered advantages including improved first attempt success, improved visibility, and improved protection ability  ...

... Confirmation of the Presence of Antibiotic Resistance Gram-Negative Bacteria in the Nina Mason Pulliam EcoLab (NMPE) by Kirby Bauer Assays and Genome Sequencing Jaipal 1 Malhi , 1 Lex , 1 Hodges , 3 Khan , 2 Francois , OMS-2, Jake OMS-2, Angela OMS-2, Zarah Chaina and Samina Akbar, PhD 1Marian University College of Osteopathic Medicine, 2 Marian University, 3Purdue University Contact: Samina Akbar., PhD Marian University College of Osteopathic Medicine. 317-955-6608 sakbar@marian.edu INTRODUCTION/ OBJECTIVE Antibiotic resistant (AR) bacteria pose a serious threat to an individuals health, and the presence of AR genes can lead to the development of superbugs that are resistant to currently used antibiotics. Identifying local reservoirs that house AR bacterial strains has become critical. The main objective of our project was to identify the presence and cause of bacterial resistance in gram-negative bacteria collected from Jensen Lake at the Nina Mason Pulliam Ecolab (NMPE). This research was conducted via two protocols. To test for AR, gram-negative bacteria isolated from the NMPE water samples were subjected to Kirby-Bauer assays (Fig. 1). To test for the presence of AR genes, genomic DNA was purified from the bacterial isolates and sent to an outside vendor (ID Genomics) for identification of potential AR genes through PCR amplification and sequencing (Fig. 2). METHODS Kirby Bauer DNA Extraction SUMMARY ENVIRONMENT Nina Mason Pulliam EcoLab RESULTS AminoGlycosides BetaLactams Cephalosporins Class: 62 (18.9%) Class: 126 (77%) 1st: 47 (57%) 2nd: 31 (38%) 3rd: 30 (18%) (1st, 2nd, & 3rd gen) Carbapenems Quinolones Sulfonamides Class: 40 (49%) Class: 62 (38%) Class: 27 (17%) Tetracyclines and Chloramphenicol Class: T: 8 (10%) C: 6 (7%) Table 1. Number and Percentage of bacterial isolates with resistance to different antibiotic classes Of the 82 isolates tested, all showed resistance to at least one antibiotic. 80 of the 82 isolates showed multi-drug resistance. Isolates were most resistant to beta-lactam antibiotics (i.e. ampicillin, amox/clav) with 77% of strains having resistance to one of the two. Other notable individual antibiotic resistances were: cephalothin (73%), ciprofloxacin (43%), imipenem (43%), and streptomycin (37%). PCR and sequencing analyses showed antibiotic resistance genes in the 130 isolates tested: CMY (53), CTX-M, TEM & SHV-1 (13 each) were the most common genes seen. Our current data shows that many of the bacterial isolates from the NMPE display resistance to commonly used antibiotics in the medical field, most namely Beta Lactams. Based on the PCR and sequencing analyses of the strains isolated thus far, 108 samples have been identified to have a gene associated with antibiotic resistance. More genetic testing is underway to identify additional antibiotic resistance genes based on the Kirby-Bauer assay data. Further research is needed to locate whether these antibiotic resistance genes are encoded on the genome, plasmids, or transposons. The long-term focus of our research is to examine the dissemination of AR genes in Indiana waterways and to document the presence of AR throughout different regions of Indiana. We also plan to test the levels of different classes of antibiotics in these water samples to see potential environmental exposures leading to increased rates of resistance. The focus on future research will also be to determine what the routes of dissemination are that lead to antibiotics being found in the waterways of Indiana. ACKNOWLEDGEMENTS Fig. 1. Example of a KirbyBauer assay Fig. 2. An example of PCR amplification of the 16S rRNA gene of the bacterial isolates from Jensen Lake at NMPE. The 894 bp 16S rRNA gene product was amplified using universal primers. The 1kb DNA ladder was run in lanes 1 and 9 of the gel. We would like to thank Marian University for allowing us to use their laboratory facilities and access to the NMPE for research. We would also like to thank Dr. Akbar, for her guidance and assistance throughout this project. This research was funded by an FRD grant and an Indiana Academy of Science grant to Dr. Akbar.  ...

... Background The kidneys remove waste, produce hormones, and control blood pressure (BP) CKD is a disease spectrum, with stage one being least severe and stage five being the most severe often requiring dialysis In CKD, the kidneys gradually stop working and manifest in various systemic issues such as heart disease, nerve damage, weak bones, fluid buildup, and hypertension 10% of Americans are affected by CKD and hypertension often accompanies Hypertension, a common risk factor for both cardiovascular disease and CKD, is often poorly controlled in patients with advanced CKD (stage 4) Additionally, hypertension accelerates the progression of CKD Therefore, it should be treated, and diuretics are helpful in doing this Are Diuretics Useful at Reducing Blood Pressure in Chronic Kidney Disease (CKD)? Yes! Chlorthalidone in Chronic Kidney Disease (CLICK) Trial Double Blind, randomized, placebo-controlled trial of chlorthalidone in patients with advanced CKD and poorly controlled hypertension Hypothesized that chlorthalidone would both decrease systolic blood pressure and albuminuria over 12 weeks Eligible patients: stage 4 CKD and blood pressure of >130/80 mmHg Nine visits in total with yearly follow-ups for three years post trial completion Results Diuretics Most diuretics decrease blood pressure by reducing the kidneys uptake of sodium There are various diuretic classes such as loop diuretics, potassium sparing diuretics, and thiazide diuretics The focus for this poster is placed on thiazide and thiazide-like diuretics Chlorthalidone, a thiazide-like diuretic, reduces blood pressure, reduces cardiovascular morbidity, such as the incidence of stroke and heart failure, and cardiovascular morbidity Since its discovery in 1957, chlorthalidone has been a mainstay therapy for reducing blood pressure Loop diuretics are effective in treating hypervolemia and hypertension in CKD but often cause acute kidney injury (AKI) Conversely, thiazide diuretics are less potent and longer acting Until recently, there was no firm data that supported the use of thiazides for improving blood pressure in advanced CKD Previous guidelines instructed physicians to switch from thiazide diuretics to loop diuretics when estimated glomerular filtration rate (eGFR) fell below 30 mL/min/1.732 However, recent evidence suggests that thiazides may have a greater role in controlling blood pressure in patients with an eGFR below 30 CLICK Trial 160 patients underwent randomization At baseline, the mean eGFR was 23.24.2 ml/min/1.73m2 The mean number of antihypertensive medications prescribe was 3.41.4 Use of gold standard blood pressure monitoring ambulatory blood pressure At randomization, mean systolic BP was 142.68.1 mmHg in the chlorthalidone group and 140.18.1 mmHg in the placebo group and the mean diastolic BP was 74.610.1 mmHg and 72.89.3 mmHg, respectively The adjusted change in SBP from baseline to 12 weeks was -11.0 mmHg in the chlorthalidone group and -0.5 mmHg in the placebo group The percent change in urinary albumin-tocreatinine ratio from baseline to 12 weeks was lower in the chlorthalidone group than in the placebo group by 50 percentage points Takeaways Andrew Cramer, MS, OMS-I Marian University College of Osteopathic Medicine Among patients with advanced CKD and poorly controlled hypertension, chlorthalidone therapy improved blood pressure at 12 weeks as compared with placebo This study proved that chlorthalidone, a drug that has been around for 65 years, is beneficial for reducing blood pressure in those with advanced CKD when it previously was contraindicated This brings up the importance of taking a second look at older medications for new indications New does not always mean better  ...

... EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2024 Effects of Mindfulness Meditation on Nurse Anesthesia Students Bridgette Stroup Marian University Leighton School of Nursing Chair: Dr. Marie Goez, DNP, CRNA (Signature) Date of Submission: November 20th, 2023 1 EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS Table of Contents Abstract....................................................................................................................................... 4 Introduction ................................................................................................................................ 4 Background ........................................................................................................................... 5 Problem Statement ................................................................................................................ 7 Needs Assessment and Gap Analysis ..................................................................................... 7 Review of the Literature .............................................................................................................. 8 Methods ............................................................................................................................... 8 Results................................................................................................................................... 9 Study Characteristics ............................................................................................................. 9 Perceived Stress ..................................................................................................................... 9 Meditation and Hypnosis ..................................................................................................... 10 Meditation Intervention ....................................................................................................... 11 Discussion ........................................................................................................................... 11 Theoretical Framework ..13 SWOT Analysis ........................................................................................................................ 13 Project Aims and Objectives ..................................................................................................... .14 Project Design ........................................................................................................................... 15 Project Site and Population .................................................................................................. 15 Measurement Instrument ..................................................................................................... 16 2 EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS Data Collection Procedure .................................................................................................. 16 Ethical Considerations ......................................................................................................... 16 Project Evaluation Plan ............................................................................................................. 17 Data Analysis ...................................................................................................................... 17 Results ...................................................................................................................................... 17 Limitations .......................................................................................................................... 18 Conclusion ............................................................................................................................... 19 References................................................................................................................................. 20 Appendices................................................................................................................................ 24 Appendix A......................................................................................................................... 24 Appendix B ......................................................................................................................... 25 Appendix C ......................................................................................................................... 26 Appendix D ........................................................................................................................ .27 Appendix E ......................................................................................................................... 28 Graph 1 ..................................................................................................................................... 29 Tables ....................................................................................................................................... 30 Table 1 ................................................................................................................................ 30 Table 2 ................................................................................................................................ 31 Table 3 ................................................................................................................................ 32 Table 4 ................................................................................................................................ 33 3 EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS 4 Abstract Introduction The future and strength of the nurse anesthesia profession starts here, with this generation of doctoral nurse anesthesia students. Setting up a foundation of healthy coping skills is key to the longevity of a healthy nurse anesthesia practice. However, nurse anesthesia students have long been known to undergo high levels of stress and anxiety due to the intense pressure and obligations of school. That goes without saying that life is inevitably filled with stressors; nonetheless, many people are ill-equipped to properly deal with and process high levels of stress. Nurse anesthesia schooling requires individuals to step away from the workforce and solely focus on academia. That means that many of these adults no longer have a reliable source of income. This creates a huge financial burden on students and their family members. With the added requirement of all nurse anesthesia schools to be doctoral-level programs, students have the additional stressors of more clinical hours, doctorate coursework, a longer duration of education, higher financial debt, scholarly projects, and lengthened practicum hours. Associated with school stressors are personal and emotional strains that students may inevitability face from day-to-day living. This immense amount of stress can have lasting consequences and places students at increased risk of anxiety, depression, extreme fatigue, burnout, substance use, dropping out, and suicidal ideation or attempt (Mainwarning et al., 2021). Without the tools and skills necessary to combat stress, unhealthy habits can lead postgraduate providers to experience adverse outcomes as a consequence of poorly managed high stress. After graduation, now practicing providers must be able to make decisions in high-stress situations where critical thinking is vital to patient care (Romito et al., 2020). This high-stress environment can lead providers to easily develop burnout (Romito et al., 2020). Burnout is EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS 5 detrimental to a provider's well-being and negatively impacts patient care; burnt-out employees are associated with less favorable patient satisfaction feedback and compromise the quality of care provided (Cocchiara et al., 2019). Unfortunately, most people do not have the knowledge or skills necessary to deal with such high stress levels (Farrar et al., 2020). Instead, to combat chronic stress, millions of Americans turn to prescription drugs. However, this can lead to providers becoming over-medicated or even addicted (Farrar et al., 2020). Adverse side effects from anti-anxiety medications, such as sedation, dependence, and drowsiness, can occur, which may affect the quality of care given to patients (Farrar et al., 2020). Due to the unfavorable side effects of many anxiolytic drugs, other holistic options, such as mindfulness, should be explored. Along with stress and burnout, nurse anesthesia providers are at high risk for drug diverging due to the easy access of highly addictive drugs (Valdes, 2014). Importantly, most anesthesia providers do not begin diverging drugs until at least ten years into their practice (Valdes, 2014). Therefore, substance use is something they need to acknowledge that can happen to them at any point in their career. Thus, we should determine if providers who are educated about how to adapt and deal with stressful situations will have increased patient safety and decreased burnout and drug divergence throughout a nurse anesthetist's lifetime. Background With little to no emphasis on mental health or stress management within the culture of nurse anesthesia schools, students continue to report high levels of stress, demonstrating a need for intervention (Mainwarning et al., 2021). Stress and anxiety are inevitable emotions of the human experience that evolutionally helped humans navigate their environment and away from danger (Schneiderman et al., 2005). Today, in small doses, these emotions allow for growth, healthy adaption, and create motivation (Schneiderman et al., 2005). However, chronic elevation EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS 6 of stress causes systemic inflammation throughout the body having physical, mental, and emotional adverse side effects (Yaribeygi et al., 2016). The chronic rise in cortisol levels from stress causes a cascade of changes that affects every major system in the body: the cardiovascular, endocrine, respiratory, nervous, and immune systems (Yaribeygi et al., 2016). This maladaptive response causes pathological responses that are associated with cardiovascular disease: coronary heart disease, high blood pressure, and atherosclerosis; suppressed immunity; increased vulnerability to infections and the common cold; slower wound healing; and poorer response to vaccinations (Yaribeygi et al., 2016). Mental and emotional effects from high levels of stress have been linked to poor school performance, cognitive impairment, sleep problems, malaise, eating disorders, fatigue, anxiety disorders, memory loss, increased consumption of alcohol, decreased levels of compassion and empathy, and mild to severe PTSD (Yaribeygi et al., 2016). To decrease adverse side effects from stress and increase optimal learning, stress management tools should be integrated into graduate nurse anesthesia schools. Furthermore, being able to make decisions in stressful situations is an important aspect of the nurse anesthesia profession. Therefore, having a strong understanding of how to manage stress and anxiety is vital for students and seasoned providers. One solution to this problem is practicing mindfulness meditation. Mindfulness Based Stress Reduction (MBSR) is an evidencebased intervention that is used to reduce stress among individuals (Burgstahler et al., 2019). Meditation mindfulness is a free tool that can be done anywhere, anytime, and can last any amount of time the participant chooses. The most common way to meditate is to sit in a quiet place in a comfortable seat, actively relaxing each part of the body. Then, with the eyes closed, gentle focus is placed on the inhalation and exhalation of each breath. This allows the mind to EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS 7 slow down, calms the nervous system, and trains the brain to focus on one thought at a time (Ching et al., 2015). It was shown that examination performance is highly dependent on preparation, quality and quantity of sleep, diet, exercise, and effective stress management (Fowler et al., 2017). Meditation is one form of effective stress management. Meditation gives one the ability to become more self-aware, label their feelings, and thus better manage negative emotions (Ching et al., 2015). Mindfulness meditation is related to increased levels of compassion and empathy, reduced anxiety, improved well-being, decreased psychological distress, and increased immune function (Burgstahler et al., 2019). In one study, mindfulness meditation was shown to increase both memory and attention among students, leading to improved learning effectiveness (Ching et al., 2015). As little as 5-10 minutes of meditation a day have been shown to have major impacts on decreasing stress and increasing wellness in medical college students (Burgstahler et al., 2019). Problem Statement It is essential to understand that student registered nurse anesthetists (SRNAs) are the future of the nurse anesthesia profession. This generation of students needs the necessary skills and tools to succeed both professionally and personally. With so many adverse outcomes, it is essential that nurse anesthesia students adequately manage stress. To improve student wellness and decrease stress and anxiety, programs should explore the use of daily meditation. This led to the development of the following PICOT question: In nurse anesthesia students, what is the effect of meditation on reducing stress levels? Needs Assessment & Gap Analysis EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS 8 This project will take place at a small private college in a large Midwest city. Here, anesthesia students continue to be placed in high pressure situations with demanding clinical and academic workloads. As with most universities, mental health is overlooked. Yet, there are simple, free ways to combat stress and anxiety, such as practicing meditation or mindfulness. Currently, at this institution, there is no formal or informal training for stress management related to mindfulness meditation. The discussion on mental health, student well-being, and emotional health needs to be opened and intensely explored. Review of the Literature Methods This literature review (Table 4) was conducted to examine the effects of meditation on college students. The review was conducted in December 2022 using the database PubMed. The review search was conducted using the keywords meditation, anxiety, college, students, and mindful-. The database searches were performed using the BOOLEAN phrases meditation AND college AND anxiety AND student nurse AND students, and mindfulness AND college AND students AND anxiety. In addition, reference lists of relevant articles and studies were manually searched for articles that met the inclusion and exclusion criteria. From the database search, 507 results were found; after duplicates were removed, 201 remained. Articles were then excluded if they were published over five years ago, not written in English, not a randomized control design, or participants were under 18 years old, which resulted in 31 research articles, as shown in the PRISMA flow chart (Appendix C). The studies were included if they met the following criteria: published over the past five years, written in English, a randomized control design, and participants over 18 years old. From the remaining results, those that were not conducted in the United States, Ireland, Australia, or New Zealand and those that were not solely done on college EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS 9 students were excluded. In all, a total of 10 randomized control trial research articles that investigated the effects of meditation on college students were included in this literature review. Results Initially, 507 articles were retrieved from the electronic database. After applying the inclusion and exclusion criteria, the search was narrowed to 10 articles. The PRISMA flow chart, shown in Appendix C, displays the selection process for this literature review. Summaries of the included studies are illustrated in the literature review matrix shown in Table 4. Study Characteristics All ten studies were designed and conducted as randomized controlled trials. The meditation interventions included the use of phone applications such as Headspace and Calm, pre-recorded guided meditations, and in-person guided meditation and hypnosis. The meditation interventions had varying durations, lasting 10 to 60 minutes. Some studies collected information after one session, while others followed college students over one academic year with varying sessions. All ten studies took place in English-speaking countries, which were the United States (n=7), Ireland (n=1), Australia (n=2), and New Zealand(n=1). Of the ten studies, four of them only used participants enrolled in health science programs at the college level. Each study focused on differing primary outcomes, which include but are not limited to anxiety, perceived stress, burnout, general well-being, resilience, mindfulness, critical thinking, executive attention, self-compassion, college adjustment, and social and nature connectedness. Common data collection tools utilized include the Perceived Stress Scale (PSS) -5, the Five-Facet Mindfulness Questionnaire (FFMQ) 4, and the Positive and Negative Affect Schedule (PANAS)- 2. Perceived Stress EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS 10 Five of the ten studies found that meditation decreased perceived stress by mean of the Perceived Stress Scale (PSS) (Barry et al., 2019; Burger et al., 2017; Chu et al., 2022; Huberty et al., 2019; Yang et al., 2018). In one RCT of 88 medical students, the meditation intervention of guided meditation was introduced to participants through the mobile application Headspace (Yang et al., 2018). The purpose of this study was to evaluate the effects of daily meditation on medical students' well-being and perceived stress (Yang et al., 2018). Participants were broken up into an intervention group and a control group (Yang et al., 2018). The intervention group was asked to complete daily meditations through Headspace for 30 days (Yang et al., 2018). The control group, or the wait group, was told they would start the meditation in the months to come (Yang et al., 2018). All participants were asked to complete the Perceived Stress Scale (PSS) at the same time, prior to starting meditation for the intervention group and again after 30 days (Yang et al., 2018). The results indicated that perceived stress significantly decreased in the intervention group compared to the control group after 30 days (p=.02) (Yang et al., 2018). Meditation and Hypnosis One of the ten studies compared the effects of meditation and hypnosis on college students (Gloede et al., 2021). In this RCT of 104 college students, participants were either placed in the hypnosis or the mindfulness meditation group (Gloede et al., 2021). In the hypnosis group, students were guided through a 15-minute hypnosis session led by the investigator (Gloede et al., 2021). In the meditation group, students were placed in a room and instructed to follow the recording of a guided 15-minute mindfulness meditation (Gloede et al., 2021). Using the Waterloo Stanford Group Scale of Hypnotic Susceptibility (WSGC)- Form C and the Inner Subjective Experiences Rating Scale (INSUB), students were asked to complete each scale before and after their sessions (Gloede et al., 2021). Both the hypnosis and mindfulness EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS 11 meditation showed a significant reduction in the WSGS results (both p<.05) compared to the baseline data, indicating that hypnosis and mindfulness meditation are notably similar in producing momentary mindful states, and both move people into a state of relaxation (Gloede et al., 2021). Meditation Intervention Eight of the ten studies utilized pre-recorded guided meditations as their intervention (Aspy et al., 2017; Barry et al., 2019; Burger et al., 2017; Chu et al., 2022; Flett et al., 2020; Huberty et al., 2019; Noone et al., 2018; Yang et al., 2018). Of these eight studies, five used the application Headspace. (Chu et al., 2022; Flett et al., 2020; Huberty et al., 2019; Noone et al., 2018; Yang et al., 2018). In one study of 91 university students, participants were placed in either the intervention group, which utilized meditation through Headspace or the control group, which utilized a sham meditation through Headspace (Noone et al., 2018). Measurements were taken before the implementation of the meditation and sham meditation and again after six weeks (Noone et al., 2018). Significant results failed to be shown in the meditation group compared to the sham meditation group for critical thinking, wellness, and emotional experience (p>.05) (Noone et al., 2018). Yet, after six weeks, both the control and the intervention group had significant changes (p<.05) from baseline, stating that both were effective in increasing wellbeing and emotional experiences (Noone et al., 2018). Discussion Combating stress, anxiety, and burnout in nurse anesthesia students is essential to the health and wellness of these students. The literature provides many examples supporting the benefit of meditation on college students. Furthermore, the results of this literature review support the use of meditation as an effective, inexpensive treatment to decrease stress and EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS 12 anxiety and increase general well-being in students. College students should be encouraged to practice mindfulness meditation through the phone applications Headspace or Calm or other forms of evidence-based guided meditation. One of the ten studies did not support the use of meditation compared to the sham group for decreasing stress (Noone et al., 2018). However, it is worth noting that the sham meditation group participants were asked to close their eyes and guided through breathing exercises using the application Headspace; users could have reasonably believed it was mindfulness training (Noone et al., 2018). Generally speaking, guided breathing exercise is considered a means of mindfulness meditation (Noone et al., 2018). For this reason, further exploration of the effects of meditation on college students without the use of guided breathing exercises as a sham group should be completed (Noone et al., 2018). From these ten articles, the limitations include smaller than 250 participant sample sizes, data collection from one day to 1 year, and no samples on doctoral nurse anesthesia students. Future studies would benefit from larger sample sizes, multiple colleges, and the inclusion of nurse anesthesia students. Future studies are recommended to evaluate the effects of meditation on nurse anesthesia students and its lasting implications regarding stress, anxiety, burnout, and mindfulness beyond one year. In conclusion, doctoral nurse anesthesia programs should promote and educate students on guided mindfulness meditation. Guided meditation is an easy approach to combat stress and anxiety and increases attention and alertness. Meditation is affordable and can be done anywhere, which makes it an excellent choice for first-line treatment, keeping pharmacological drugs as the next approach. Students may benefit from a constant mindful meditation practice, setting themselves up for success as healthcare providers. EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS 13 Theoretical Framework The Symptom Management Theory is a framework used to help guide symptom assessments, treatments, and desired outcomes for research and practice. It was developed by Melinda S. Bender, Susan L. Janson, Linda S. Franck, and Kathryn Aldrich Lee in 1994 at the University of California School of Nursing, San Francisco, and later revised in 2001(Smith & Liehr, 2018). Previous models, such as the Model of Symptoms of Self-Care and Self-Care Model, were the foundations from which the Symptom Management Model was derived (Smith & Liehr, 2018). As shown in Appendix A, this theory has three main concepts: symptom experience, symptom management strategies, and symptom status outcomes (Smith & Liehr, 2018). These three main concepts are explored in relationship to the three domains of nursing science: person, environment, and health/illness (Smith & Liehr, 2018). This framework allows for the broad, complex topic of symptom management to be readily organized, studied, and incorporated into practice. Applying the Symptom Management Theory as a framework to the problem of student stress would help assess the effects of meditation on stress. First, stress symptoms experienced are clearly identified. Next, a management strategy is applied; in this case, the management strategy is meditation. Then, stress symptoms are reevaluated after the meditation intervention is complete. If the reported symptoms decrease in severity or disappear altogether, then according to the Symptom Management Theory, meditation is an effective treatment for stress management. This theory provides a valuable framework when applying it to the management of symptoms from stress by means of meditation. SWOT Analysis EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS 14 The key stakeholders for this project are doctoral nurse anesthesia students and nurse anesthesia programs. Other stakeholders include hospitals, patients, and insurance companies. The intent of this project is to shine a light on stress and how meditation can be easily taught to decrease stress levels and its associated symptoms among nurse anesthesia students. The SWOT analysis chart, shown in Appendix B, displays the strengths, weaknesses, opportunities, and threats to this project. Anticipated strengths for this project include convenience, costeffectiveness, the use of technology, and a foundational meditation class that was previously taught to nurse anesthesia students at the university. This project is considered convenient because participants can meditate anywhere, any time of the day. More so, this project is free to all parties involved and only requires downloading an app. Using technology is a significant strength of this project because it will support the meditation app and the pre and post-surveys. Additionally, this class of students is not naive to concepts of meditation because, during a mandatory wellness day held on campus, the nurse anesthesia students of one university were given an intro to meditation class. This class is anticipated to strengthen the meditation skill level of these students. However, weaknesses or potential barriers to this project include students with low commitment who are not willing to participate. Opportunities for this project are important as mental health is gaining more attention, and a need for stress management in students is identified. This project has the potential to highlight the importance of stress management and spread awareness of the effects of meditation. Perhaps nurse anesthesia schools will identify meditation as an essential skill that needs to be implemented and taught to all their students. Lastly, threats to this project include a lack of support from nurse anesthesia programs and a lack of support or willing participation from students. Project Aims and Objectives EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS 15 The purpose of this project is to increase the health and wellness of doctoral nurse anesthesia students through meditation. Due to the high demands from school, stress is a common concern among nurse anesthesia students. Research has shown that meditation can be used to combat stress. Therefore, decreasing the levels of stress students experience is expected to increase their quality of well-being. This project aims to assess mindfulness meditation's effects on reducing stress in doctoral nurse anesthesia students. Students will be asked to participate in one 5-minute guided meditation. Afterward, the collected data will be examined, and pre- and post-meditation scores on stress levels will be analyzed. The quantitative objective includes the following: the average post-meditation stress levels reported decreased from premeditation stress levels. The qualitative objective consists of the following: the students will list fewer side effects related to their stress by the end of the seven days of meditation compared to the beginning. The expected outcome is that students report decreased stress levels after doing the evidence-based mindfulness meditation. Project Design Project Site and Population For this proposed project, the study will take place at a private Catholic university in central Indiana. The population for this project will include both sexes of any age who are currently in school for nurse anesthesia. The inclusion criteria will be graduate, doctoral nurse anesthesia students. Exclusion criteria will be anyone not currently enrolled as a nurse anesthesia student. Students will be asked to participate in one 5-minute meditation. Afterward, the collected data will be examined, and pre- and post-meditation scores on stress levels will be analyzed. To allow for easy interaction with all participants, the intervention will be held online. To allow for EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS 16 flexibility, the participants will be given roughly four weeks to complete the meditation intervention with the pre-and post-questionnaire, which may be done from the location of their choice. A barrier to participation in this project may be access to the internet; however, Marian University offers free Wi-Fi and computer access to all students and faculty. Measurement Instruments In order to evaluate the effects of meditation on nurse anesthesia students, a pre-and postquestionnaire was created by the project leader (see Appendix D). Data Collection Procedures To collect this data, the online site qualtrics.com through Marian University will be utilized. This site allows for easy data collection and keeps the results of the survey private so that only the owner may see the results. All participants will remain anonymous and will only be identified by entering the last four digits of their student ID before starting each survey. An implied consent will be presented to the participants before beginning the survey and meditation (see Appendix E). Ethical considerations Participants' confidentiality will be assured by coding the participants using the last four digits of their student ID. This means all results will be anonymous as the project coordinator does not have access to any database to identify students with their student ID numbers. Any electronic information with identifiable data, such as the surveys, will only be accessible to the project coordinator. This electronic information will include a password to access it to prevent access by unauthorized users. Non- augurated data will be deleted after two years. All electronic raw data collected and stored will be kept for five years and then deleted. There are minimal to EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS 17 no risks to those participating in this project, as meditation has been shown to be a safe stress reduction. Project Evaluation Plan Data Analysis To evaluate the effectiveness of the project, statistical analysis will be performed on the quantitative questions. To assess the multiple-choice questions, post-intervention questions will be compared to pre-intervention questions. To evaluate the effectiveness of the qualitative questions, a qualitative analysis will be performed utilizing Lincoln and Guba's trustworthiness (Meadows-Oliver, 2019). The project leader will ensure credibility, transferability, dependability, and confirmability throughout (Meadows-Oliver, 2019). The data will be discussed for interpretation and include areas of potential bias. Finally, conclusions will be drawn on whether meditation was an effective tool for stress decreasing stress in nurse anesthesia students. Results A total of 104 students were invited to participate in this study, and of those, 38 students completed the pretest and 36 completed the posttest. From these findings, 2 subjects were excluded due to failure to complete the posttest. As shown in Table 1, the demographics of the 36 participants (n=36) were 69% females (n=25) and 31% were males (n=11); 53% were 1st years (n=19), 17% were 2nd years (n=6), and 31% were 3rd years (n=11); 42% were between the ages of 22-28 (n=15), 45% were between the ages of 29-35 (n=16), 8% were between the ages of 36-42 (n=3), and 5% were 43 and over (n=2). Additionally, two pretest questions asked participants if they had ever meditated before and how many times they had meditated in the past month. Table 2 illustrates that 81% of EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS 18 participants had meditated before (n=29), and 19% of them reported never having meditated (n=7). However, only 36% of the participants reported meditating 1-4 times in the past month (n=13), and 64% had not done any meditation practice in the past month (n=23). None of the participants reported meditating more than four times in the past month. The outcomes of this project were assessed based on the changes found in the pre- and post-test. Table 3 highlights the comparison between questions 7 and 9, where participants were asked to rate their current level of stress pre and post-meditation on a scale from 0 -10, zero being completely relaxed, they could fall asleep, to 10 they were having a panic attack. Premeditation responses ranged from 1-10, with a mean stress level of 5.11. Post-meditation responses ranged from 0-7, with an average stress level of 2.83. Thus, the average stress level decreased by 2.28 after completing the 5-minute guided meditation. Lastly, after the meditation, participants were asked to describe how they felt now by selecting all that applied; seven options were given to them, and one option was given as other, please specify, where they could write how they were feeling. Graph 1 depicts how the participants were feeling after the meditation: 78% felt calmer (n=28), 67% felt less tense (n=24), 50% felt peaceful (n=18), 36% felt lighter (n=13), 22% felt more focused (n=8), and 33% felt grateful (n=12). Of the 36 participants, 5 people chose other, please specify and added phrases like my heart is more open, I feel nice, and the same amount of stuff to do. However, none of the answers were repeated more than once, thus making them insignificant to the studys findings. Limitations The limitations of this study include a small sample size from one university, a relatively short meditation session, and a singular meditation session. Future studies would benefit from a EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS 19 larger sample size, including multiple nurse anesthesia universities, a longer meditation session, and more than a single meditation session. Future studies are recommended to evaluate the effects of meditation on nurse anesthesia students and its lasting implications beyond a one-time session. Conclusion Nurse anesthesia students are reporting high stress levels, with an average stress level of 5.11 on a scale from 0-10. However, after one short 5-minute guided meditation, the average stress score of these very same students decreased to 2.83. That means that a single meditation session can decrease ones current stress level by roughly 2.28 points. Additional benefits found in a one-time 5-minute guided meditation include increased feelings of calmness, peacefulness, lighter, less tense, more relaxed, and gratefulness. In conclusion, the results of this project suggest that a one-time 5-minute guided meditation is an effective free tool that can be utilized for decreasing acute stress in nurse anesthesia students. With so much at stake, as our future anesthesia providers, nurse anesthesia schools should consider integrating mindfulness techniques, offering meditation-based tools to their students, and educating them on the benefits of incorporating meditation into their lives. EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS 20 References Aspy, D. J., & Proeve, M. (2017). Mindfulness and loving-kindness meditation. Psychological Reports, 120(1), 102117. https://doi.org/10.1177/0033294116685867 Barry, K. M., Woods, M., Martin, A., Stirling, C., & Warnecke, E. (2019). A randomized controlled trial of the effects of mindfulness practice on doctoral candidate psychological status. Journal of American College Health : J of ACH, 67(4), 299307. https://doi.org/10.1080/07448481.2018.1515760 Burger, K. G., & Lockhart, J. S. (2017). Meditation's effect on attentional efficiency, stress, and mindfulness characteristics of nursing students. The Journal of Nursing Education, 56(7), 430434. https://doi.org/10.3928/01484834-20170619-08 Burgstahler, M. S., & Stenson, M. C. (2019). Effects of guided mindfulness meditation on anxiety and stress in a pre-healthcare college student population: A pilot study. Journal of American College Health, 68(6), 666672. https://doi.org/10.1080/07448481.2019.1590371 Cocchiara, R. A., Peruzzo, M., Mannocci, A., Ottolenghi, L., Villari, P., Polimeni, A., Guerra, F., & La Torre, G. (2019). The use of yoga to manage stress and burnout in healthcare workers: A systematic review. Journal of Clinical Medicine, 8(3), 284. https://doi.org/10.3390/jcm8030284 Ching, H., Koo, M., Tsai, H., & Chen, Y. (2015). Effects of a mindfulness meditation course on learning and cognitive performance among university students in Taiwan. Evidencebased Complementary and Alternative Medicine : eCAM, 2015. https://doi.org/10.1155/2015/254358 EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS 21 Chu, A., Rose, T. M., Gundrum, D. A., McMorris, T. E., Klausner, E. A., Lang, L. A., & Shan, G. (2022). Evaluating the effects of a mindfulness mobile application on student pharmacists' stress, burnout, and mindfulness. American Journal of Health-System Pharmacy, 79(8), 656664. https://doi.org/10.1093/ajhp/zxab467 Farrar, A. J., & Farrar, F. C. (2020). Clinical aromatherapy. The Nursing Clinics of North America, 55(4), 489504. https://doi.org/10.1016/j.cnur.2020.06.015 Flett, J. A. M., Conner, T. S., Riordan, B. C., Patterson, T., & Hayne, H. (2020). App-based mindfulness meditation for psychological distress and adjustment to college in incoming university students: a pragmatic, randomised, waitlist-controlled trial. Psychology & Health, 35(9), 10491074. Fowler, A., Whitehurst, K., Al Omran, Y., Rajmohan, S., Udeaja, Y., Koshy, K., & Gundogan, B. (2017). How to study effectively. International Journal of Surgery. Oncology, 2(6), e31. https://doi.org/10.1097/IJ9.0000000000000031 Gloede, M. E., Sapp, M., & Van Susteren, W. (2021). Hypnosis and mindfulness meditation: the power of suggestibility. The International Journal of Clinical and Experimental Hypnosis, 69(4), 411421. https://doi.org/10.1080/00207144.2021.1908830 Huberty, J., Green, J., Glissmann, C., Larkey, L., Puzia, M., & Lee, C. (2019). Efficacy of the mindfulness meditation mobile app "Calm" to reduce stress among college students: randomized controlled trial. JMIR mHealth and uHealth, 7(6), e14273. https://doi.org/10.2196/14273 Jagoda, T., & Rathnayake, S. (2021). Perceived stress and learning environment among nursing students: A cross-sectional study. Collegian, 28(5), 587594. https://doi.org/10.1016/j.colegn.2021.03.003 EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS 22 Mainwarning, J., & Mesisca, J. (2021). Stress, Anxiety, and Well-being in Nurse Anesthesia Doctoral Students. AANA Journal, 89(5), 396-402. https://www.aana.com/docs/defaultsource/aana-journal-web-documents-1/mesisca-r.pdf?sfvrsn=ad7ccda3_4 Meadows-Oliver, M. (2019). Critically appraising qualitative evidence for clinical decision making. In B. M. Melnyk., & Fineout-Overholt, E. (Ed.), Evidenced-based practice in nursing and healthcare: A guide to best practice (4th edition). Wolters Kluwer. Noone, C., & Hogan, M. J. (2018). A randomized active-controlled trial to examine the effects of an online mindfulness intervention on executive control, critical thinking and key thinking dispositions in a university student sample. BMC Psychology, 6(1), 13. https://doi.org/10.1186/s40359-018-0226-3 Romito, B. T., Okoro, E. N., Ringqvist, J., & Goff, K. L. (2020). Burnout and wellness: The anesthesiologist's perspective. American Journal of Lifestyle Medicine, 15(2), 118125. https://doi.org/10.1177/1559827620911645 Schneiderman, N., Ironson, G., & Siegel, S. D. (2005). Stress and health: psychological, behavioral, and biological determinants. Annual Review of Clinical Psychology, 1, 607 628. https://doi.org/10.1146/annurev.clinpsy.1.102803.144141 Smith, M.J. & Liehr, P. P. (2018). Middle range theory for nursing (4th ed.). Springer Publishing Company Stinson, C., Curl, E. D., Hale, G., Knight, S., Pipkins, C., Hall, I., White, K., Thompson, N., & Wright, C. (2020). Mindfulness meditation and anxiety in nursing students. Nursing Education Perspectives, 41(4), 244245. https://doi.org/10.1097/01.NEP.0000000000000635 EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS 23 Syliva, M. (2021). Data management and evaluation of translation. In White, M. K., DudleyBrown, S., & Terhaar, F. M. (Eds), Translation of Evidence Into Nursing and Healthcare (3rd edition). Springer Publishing Company. Valdes, J. A. (2014). The concept of reentry in the addicted anesthesia provider. AANA Journal, 82(2), 95100. Yang, E., Schamber, E., Meyer, R. M. L., & Gold, J. I. (2018). Happier healers: Randomized controlled trial of mobile mindfulness for stress management. Journal of Alternative and Complementary Medicine (New York, N.Y.), 24(5), 505513. https://doi.org/10.1089/acm.2015.0301 Yaribeygi, H., Panahi, Y., Sahraei, H., Johnston, T. P., & Sahebkar, A. (2016). The impact of stress on body function: A review. EXCLI Journal, 16, 1057-1072. https://doi.org/10.17179/excli2017-480 EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS 24 Appendix A Smith, M.J. & Liehr, P. P. (2018). Middle range theory for nursing (4th ed.). Springer Publishing Company 25 EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS Appendix B Effects of Mindfulness Meditation SWOT Analysis Strengths Convenient; can be done anywhere Weaknesses Undesirable length of time Opportunities Need for stress management Cost-effective; free Meditation knowledge deficit Technology; apps on everyone's phone Intro to meditation class previously taught to students Low commitment from students Mental health popularity on the rise Identify new effective tool for combating stress Implementing taught meditation in SRNAs Threats Lack of support from school/program Lack of support from students EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS Appendix C PRISMA 2022 Flow Diagram Identification Identification of studies via databases Records identified from PubMed Databases (n = 507) Screening Records screened (n = 201) Included Reports assessed for eligibility (n = 31) Studies included in review (n = 10) Records removed before screening: Duplicate records removed (n = 306) Records excluded (n = 170) Reports excluded: Reason 1 (n = 10) study was not done in the United States, Australia, New Zealand, or Ireland Reason 2 (n = 11) study was not college students 26 EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS 27 Appendix D 1. What gender do you identify as? a. female b. male c. non-binary 2. What age group do you fall into? a. 22-28 b. 29-35 c. 36-42 d. 43 and over 3. As an SRNA, what year are you? a. 1st year b. 2nd year c. 3rd year 4. Have you ever meditated? a. Yes b. No 5. In the past month, how many times have you meditated? a. 0 b. 1-4 c. 4-8 d. 9+ 6. On a scale from 0-10, rate your current stress level; zero being completely relaxed, you could fall asleep, to 10 you are having a panic attack. a. 0-10 7. Now that you have completed the guided meditation, please reassess your stress level. On a scale from 0-10, rate your current stress level; zero being completely relaxed, you could fall asleep, to 10 you are having a panic attack. a. 0-10 8. After completing the meditation, please describe how you feel now. Select all that apply. a. Calmer b. Less tense c. Peaceful d. Lighter e. More focused f. Grateful g. Other: Please specify ____________________ EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS 28 Appendix E You are invited to participate in a guided meditation. This study is being conducted by Bridgette Stroup (primary investigator) from Marian University in fulfillment of her DNP graduate project. You were selected to participate in this study because you are a student enrolled in the nurse anesthesia program at Marian University. The purpose of this project is to study the effects of mediation on SRNAs. If you agree to take part in this study, you will be asked to complete the survey on the next page. This survey will ask about your experience with meditation and your current stress level. It will take you approximately 15 minutes to complete. Your answers in this study will remain confidential and results will be reported in the aggregate. Any risks to breach of confidentiality will be minimized by storage of all data in a password-protected computer kept in the home of the primary investigator and the deletion of all data upon completion of the study. Your participation in this study is completely voluntary and you can withdraw at any time. You are free to skip any question you choose. If you have questions about this study or if you have a study-related problem, you may contact the primary investigator, Bridgette Stroup at (412) 913-7128. If you have any questions concerning your rights as a study subject, you may contact the Marian University Institutional Review Board Chair at irb@marian.edu. By completing the pre-survey, you are indicating that you are at least 18 years old, have read and understood this consent form, and agree to participate in this study. EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS Graph 1 Participant Qualitative Results 29 30 EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS Table 1 Participant Demographics Survey Question Characteristics Frequency Percentage What gender do you identify as? a. b. c. Female Male Non-binary a. b. c. 25 11 0 a. b. c. 69% 31% 0% What age group do you fall into? a. b. c. d. 22-28 29-35 36-42 43 and over a. b. c. d. 15 16 3 2 a. b. c. d. 42% 45% 8% 5%. As an SRNA, what year are you? a. b. c. 1st year 2nd year 3rd year a. b. c. 19 6 11 a. b. c. 53% 17% 31% *Percentages were rounded to the nearest whole number 31 EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS Table 2 Participant Quantitative Results Survey Question Characteristics Frequency Percentage Have you ever meditated? a. b. Yes No a. b. 29 7 a. b. 81% 19% In the past month, how many times have you meditated? a. b. c. d. 0 1-4 4-8 9+ a. b. c. d. 23 13 0 0 a. b. c. d. 64% 36% 0% 0% *Percentages were rounded to the nearest whole number EFFECTS OF MEDITATION ON NURSE ANESTHESIA STUDENTS 32 Table 3 Participant Pre and Post Quantitative Results A. Survey Question 7- On a scale from 0-10, rate your current stress level; zero being completely relaxed, you could fall asleep, to 10 you are having a panic attack. Minimum Maximum Mean Variance Mode 1.0 10.00 5.11 3.41 4.0 B. Survey Question 9- Now that you have completed the guided meditation, please reassess your stress level. On a scale from 0-10, rate your current stress level; zero being completely relaxed, you could fall asleep, to 10 you are having a panic attack. Minimum Maximum Mean Variance Mode 0.0 7.0 2.83 3.08 2.0 EFFECTS OF MEDITATION ON COLLEGE STUDENTS Table 4. Literature Review Matrix Author/Year Study Design Sample (n=x) Meditation Intervention Instruments / Data collection Results Aspy et al. Randomized Controlled Trail N= 115 Guided meditation Mp3 recordings Survey Monkey, Connectedness to Nature Scale (state version), Positive and Negative Affect Schedule (PANAS), Social Connectedness Scale The mindfulness and lovingkindness meditation groups had significant greater social and nature connectedness than those in the control group (p<.05). Guided mindfulness practice using an audio CD Depression, Anxiety and Stress Scale (DASS), Perceived Stress Scale (PSS), Psychological Capital Questionnaire (PCQ) Compared to the control group, the intervention group reported a statistically significant increase in hope (p=.000), selfefficacy (p=.004), and resilience (p=.011), and a reduction in depression (p=.045). Guided mindfulness meditation using audio file The Five-Facet Mindfulness Questionnaire (FFMQ), Perceived Stress Scale (PSS-10), The Attention Network Test (ANT) The meditation group significantly reduced stressed (p=.000), increased mindfulness (p=.013), and enhanced executive attention (p=.044). 2017 Barry et al. 2019 Burger et al. 2017 Undergraduate students Randomized Controlled Trail N=83 Randomized Controlled Trail N=52 Doctoral students Nursing students Mindfulness meditation (MM), loving-kindness meditation (LKM), progressive muscle relaxation (active control group) 34 Effects of Mindfulness Chu et al. 2022 Flett et al. 2020 Gloede et al. 2021 Huberty et al. 2019 Randomized Controlled Trail N=56 Randomized Controlled Trail N= 250 Randomized Controlled Trail N=104 Headspace; a mobile application Perceived Stress Scale (PSS), Mindfulness Attention Awareness Scale (MAAS), Maslach Burnout Inventory (MBI) Compared to the control group, the intervention group showed a significant reduction in stress and burnout and an improvement in mindfulness (p<.05). Headspace; a mobile application Kessler Psychological Distress Scale, College Adjustment Test, Brief Resilience Scale, New General Self-Efficacy Scale, Cognitive Affective Mindfulness Scale Revised, academic scores Moderate use of Headspace users reported an improvement in psychological distress(p<.001) and an increase in college adjustment(p<.001). Pre-recorded mindfulness meditation or a live guided hypnosis Waterloo Stanford Group Scale of Hypnotic Susceptibility (WSGC)Form C, Inner Subjective Experiences Rating Scale (INSUB) Hypnosis and mindfulness meditation both showed significant reduction in the WSGS results (both p<.05) and no significant difference between the two on the WSGC results (p>.05). Pharmacy students First year college students College students Randomized N=88 Controlled Trail College students Calm; a mobile application Perceived Stress Scale, Five Factor Mindfulness Questionnaire (FFMQ), Self-Compassion Survey Short-Form (SCS-SF), Patient-Reported Outcomes Measurement Information System (PROMIS), Youth Risk Behavior Surveillance (YRBS) Significant differences were found in all outcomes (mindfulness, stress, and selfcompassion) in the intervention group compared to the control group (all p<.03). 35 Effects of Mindfulness Noone et al. 2018 Stinson et al. 2020 Yang et al. 2018 Randomized N= 91 Controlled Trail University students Headspace; a mobile application Halpern Critical Thinking Assessment (HCTA), Heuristics and Biases items, Five Facet Mindfulness Questionnaire (FFMQ), Sternberg working memory task, Positive and Negative Affect Schedule (PANAS), WarwickEdinburgh mental well-being scale, Real world outcomes inventory, Practice quality - mindfulness questionnaire Significant results were failed to be shown in the meditation group compared to the sham meditation group for critical thinking, wellness, and emotional experience (p>.05). Randomized N= 49 Controlled Trail Nursing students In-person Mindfulness meditation State-Trait Anxiety Inventory Trait anxiety decreased in the intervention group (p = .000). Randomized N= 88 Controlled Trail Medical students Headspace; a mobile application Perceived Stress Scale (PSS), FiveFacet Mindfulness Questionnaire (FFMQ), and General Well-Being Schedule (GWBS) Perceived stressed significantly decreased and generally well-being significantly increased in the intervention group compared to the control group (p<.05).  ...

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... 1 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2024 Effectiveness of Utilizing the Anatomage Table to Teach a Neuraxial Block Sarah Johnson Marian University Leighton School of Nursing Chair: Dr. Marie Goez, DNP, CRNA Marie Goez, DNP, CRNA (Signature) Committee member: Erica Ausel, PhD (Signature) Date of Submission: 2/12/2024 (Date) February 10, 2024 2/12/2024 (Date) 2 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK Table of Contents Abstract4 Introduction..5 Background..6 Problem Statement...7 Needs Assessment and Gap Analysis..7 Review of Literature8 Theoretical Framework..12 Project Aims and Objectives..13 SWOT Analysis.13 Project Design/Methods.14 Population/Setting..15 Measurement Instruments..16 Data Collection Procedures....16 Data Analysis.17 Ethical Considerations...17 Results17 Discussion of Findings......22 Strengths and Limitations..23 Conclusion.24 References..25 Appendices.29 Appendix A Prisma Diagram..29 Appendix B Literature Review Matrix...30 3 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK Appendix C ACE Star Model of Knowledge.34 Appendix D SWOT Analysis..35 Appendix E Knowledge Assessment Questionnaire...36 Appendix F Student Satisfaction and Self-Confidence in Learning ..38 Appendix G IRB Exemption Form.39 Appendix H Tables 40 4 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK Abstract Neuraxial blocks are widely used by anesthesia providers in primarily orthopedic and obstetric populations. In many anesthesia programs, education surrounding regional blocks is limited to the classroom setting without thorough training on anatomy. The Anatomage table is a three-dimensional digital screen that allows students to perform virtual dissections and visualize various anatomical structures in the classroom setting. Review of the literature found that the Anatomage table improves visualization of structures, enhances anatomy comprehension, and serves as a useful supplemental tool. This Doctor of Nursing Practice (DNP) project evaluates the effectiveness of the Anatomage table in enhancing Student Registered Nurse Anesthetists (SRNA) knowledge and confidence in performing neuraxial blocks, potentially informing its integration into anesthesia programs. This quality improvement project design utilized an educational intervention in addition to a pretest-posttest format containing a variety of knowledge based quantitative questions, confidence questions and Likert scale questions. A sample of 21 Marian University first-year SRNAs participated in the educational intervention session, and 7 students from the same class served as the control group. Participants who used the Anatomage table demonstrated a significant increase in knowledge (p=0.001) and reported higher satisfaction and self-confidence (p < .05), compared to the control group. However, the difference in knowledge scores between the intervention and control groups was not statistically significant (U=41, p=0.073). By incorporating this tool, SRNAs will be able to gain a deeper knowledge of various topics and be more confident in the clinical setting, allowing them to provide safe and expert care to patients. Keywords: SRNA, Neuraxial blocks, Anatomage table, education, and virtual dissection 5 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK Effectiveness of Utilizing the Anatomage Table to Teach a Neuraxial Block Student Registered Nurse Anesthetists (SRNAs) must learn an in-depth knowledge of anatomy and physiology of the human body essential and fundamental in performing the skills of safe and effective anesthesia. Currently students do not practice these procedures on cadavers; rather students develop skilled practice in the clinical setting under the supervision of licensed providers, on patients undergoing procedures. In the classroom, during introductory lessons of the human body's intricacies, it is helpful to have a visual aid present to assist the experience. This visual aid can be a traditional cadaver dissection lab or a virtual setting. Traditional anatomy teaching occurs in an anatomy lab, where students can visualize and touch structures underneath the skin such as nerves, veins, and arteries. However, anatomy labs can be expensive to maintain; there is a need for donated bodies and organs, and the number of dissections per body is limited (Martn, 2018). Additionally, human bodies need to be handled and disposed of by trained professionals and in an ethical manner (Martn, 2018). The question arises, are there advanced technological approaches that can help the student beyond textbook, simulation, cadaver, and patient learning? The Anatomage table is a technologically advanced anatomy visualization tool designed for human anatomy education. It is a three-dimensional (3-D) interactive digital screen that allows for the visualization of human anatomy and virtual dissection. Students can visualize different layers of tissue, use a virtual knife to cut away at structures and study different organs within the body (Alasmari, 2021). Unlike an anatomy lab, embalming products, special permits, or licenses are not required for utilization (Martn, 2018). Students can make longitudinal, sagittal, and horizontal sections to understand the relationships between separate body parts and internal organs (Alasmari, 2021). Another benefit is that students can choose to view female or 6 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK male-specific structures eliminating the need for multiple cadavers. In addition, the Anatomage table can be used repeatedly without the need for frequent replacement of usable human tissues. After a student is finished utilizing the table, they can reset the digital cadaver allowing a clean slate for the next student (Alasmari, 2021). Background Central neuraxial blockades such as spinal and epidural blocks are a type of regional anesthetic that involves placement of local anesthetic medication onto or near the spinal cord (Nagelhout & Elisha, 2018). The utilization of regional nerve blocks in anesthesia has increased over the past few decades and is frequently used within orthopedic and obstetric populations. This is partially due to growing recognition of opioid sparing and multimodal anesthesia techniques (Albrecht & Chin, 2020). Regional anesthesia has had a prominent and effective role in minimizing opioid requirements during surgery (Albrecht & Chin, 2020). Additionally, when compared to general anesthesia, regional anesthesia is associated with a reduction in patient mortality, morbidity, and economic outcomes such as length of hospital stay (Albrecht & Chin, 2020). At a University in Saudi Arabia, a high percentage of medical students reported satisfactions with using the Anatomage table as a supplemental tool to cadaver dissections, visualizing different body systems due to its ability to rotate the digital body and dissect various body parts, and allowing a profound understanding and visualization of anatomy through medical imaging (Alasmari, 2021). The Anatomage table has proven to be effective, with improved test scores, and students acceptance of the new technology (Anand & Singel, 2017). Accurate details along with many customizable features enhance students interests leading to more effective teaching and 7 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK educational outcomes (Anand & Singel, 2017). Removing students from the book and placing them in an interactive setting encourages exploration, repeated attempts, and practice in a low stress environment with the content being taught (Brown et al., 2015). When it comes to learning hands-on skills, students require the material to be presented in an applicable, authentic, safe, and standardized simulation practice setting. Problem Statement When performing a neuraxial block, SRNAs must have a thorough understanding of all the landmarks including muscles, ligaments, bones, and nerves and their relationship to one another. Rather than receiving only a didactic lecture on anatomy, students should benefit by visually seeing the anatomical relationships to one another in a three-dimensional (3-D) setting (Baratz et al., 2019). With a 3-D representation of anatomy where neuraxial blocks are placed, SRNAs will have a more thorough understanding of how to perform the block and have the educational readiness and confidence to perform the block in the clinical setting. With this the following PICOT question was developed: Can the Anatomage table be successfully utilized to educate Marian SRNAs on how to effectively identify pertinent anatomy and perform a neuraxial block? Needs Assessment & Gap Analysis As part of their curriculum and future scope of practice, SRNAs are expected to learn the complexities of how to perform numerous types of regional nerve blocks. At Marian University, education surrounding regional nerve blocks is limited to the classroom setting and simulation lab. It would be beneficial to utilize a visual aid that allows a thorough understanding of the anatomy and the relationship of landmarks to one another in a 3-D setting. Currently, many SRNAs are learning how to perform numerous regional blocks in the operating room with 8 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK limited exposure or practice. By utilizing the Anatomage table to educate SRNAs of important anatomy and landmarks regarding regional blocks, this study predicts that SRNAs will enter the clinical setting feeling more prepared and knowledgeable regarding the appropriate technique for performing various blocks. Review of Literature Search Methodology This literature review was completed to analyze articles regarding the use of the Anatomage table and its effectiveness in educating medical students. An initial search was conducted using simulation, nursing, Anatomage table, virtual dissection, digital anatomy, cadaver lab and digital learning. This literature review was conducted in November 2022 using the databases CINAHL and PubMed. Both databases were searched using the BOOLEAN phrases simulation OR nursing OR Anatomage table AND virtual dissection OR digital anatomy OR cadaver lab OR digital learning. The databases provided 42 search results that were reduced to exclude articles that were published over five years ago, and articles written in another language with no English translation. The remaining research articles were reviewed based on the following inclusion criteria: articles in English less than 5 years old, Anatomage table as an intervention, and individuals with anatomy backgrounds. The 42 articles were reduced to 14 articles that discussed or compared the effectiveness of using the Anatomage table as an educational tool or tested it against other tools. Please see Appendix A for the PRISMA flow diagram. Literature Review Results 9 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK This literature reviews initial search began with 42 articles. After applying both the exclusion and the inclusion criteria, the search was narrowed down to 14 articles. Appendix B shows the literature review matrix with the breakdown of information for each study. Benefits of Simulation Four out of fourteen studies conducted randomized control trials to determine whether students benefited from additional simulation training compared to traditional teaching methods (Padilha et al., 2019; Lebdai et al., 2020; Tamaki et al., 2019; Li et al., 2019). One trial evaluated the effectiveness of a clinical virtual simulation in relation to nursing students knowledge retention, clinical reasoning, self-efficacy, and satisfaction (Padilha et al., 2019, p.1). Between the two groups there was no statistical difference between self-efficacy perceptions; however, the experimental groups knowledge improved significantly immediately after the intervention (p=.001) and two months later, (p=.02) and had higher satisfaction levels (p<.001) (Padilha et al., 2019). A similar prospective controlled study compared whether immersive virtual patient simulation (IVPS) was influential in improving students academic performance. Students who participated in the IVPS achieved significantly higher grades in semester 2 than in semester 1 (p=0.002). Additionally, students in the IVPS group received higher grades than the control groups in both semesters 1 and 2 (p<0.003) (Lebdai et al., 2020). An additional advantage was students had higher levels of satisfaction with overall interest, ergonomics, realism, immersion and training efficiency (Lebdai et al., 2020). Another study evaluated whether end of life (EOL) care simulations can improve undergraduate nursing students knowledge, skill performance and self-confidence. The simulation group demonstrated a significant increase both immediately during the posttest and over time in EOL knowledge (p=0.000; p=0.000), skill performance (p=0.000; p=0.000) and self-confidence in EOL care (p=0.000) (Tamaki et al., 2019). The final 10 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK randomized control study evaluated the effectiveness of simulation-based deliberate practice on fostering undergraduate nursing students communication, empathy, and self-efficacy skills. Students who participated in the stimulation training had a significant increase in their communication ability (p<.01), empathy, and self-efficacy scores (p=.003) (Li et al., 2019). Anatomage as a Complementary tool Two out of fourteen studies determined that the Anatomage table can be utilized as a complementary tool to enhance anatomy comprehension (Anand & Singel, 2017; Olowabi et al., 2022). In a comparative study directly comparing traditional dissection versus Anatomage dissection for neuroanatomy, 84% of students were in favor of including the Anatomage table as part of their regular curriculum (Anand & Singel, 2017). In a qualitative study gathering the expert opinion from African Anatomists, the most recurring opinion of the Anatomage table was the table complements the traditional cadaver-based approaches. Olowabi et al. (2022) argued that while the Anatomage table can be used as a supplementary teaching tool, it cannot replace real-life cadaver-based approaches. Although the Anatomage table may not be able to completely replace traditional dissection, many students perception is that they benefited from its use and would like to use it as an additional learning resource. Cadaver lab compared to Anatomage Table Five out of fourteen studies directly compared students learning with Anatomage table versus traditional dissection, however whether the results were statistically significant varied among the studies (Anand & Singel, 2017; Baratz et al., 2019; Bin Abdulrahman et al., 2021; Kausar et al., 2020; Washmuth et al., 2019). In a comparative study between Anatomage table and traditional dissection regarding neuroanatomy, there was no statistically significant difference between students who learned with one technique over the other (p=0.0979) (Anand & 11 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK Singel, 2017). A case study evaluated whether the Anatomage table would provide an equivalent educational opportunity for a pregnant student who could not participate in the usual cadaver labs (Washmuth et al., 2019). Every test the pregnant student took fell within the interquartile range of grades of the median values for the group that participated in cadaver dissection. The pregnant student's performance equally compared to the grades of the cadaver dissection group (Washmuth et al., 2019). Another study compared the Anatomage table versus cadaver dissection for two different topics: Pelvis and Perineum (P/P) or Musculoskeletal (MSK). There was no difference between the two modalities for P/P, but for the topic of MSK the Anatomage table had a significantly higher average quiz score on the post lab quiz (p=0.03) (Baratz et al., 2019). In a cross-sectional study, comparing the plastinated models with the Anatomage table demonstrated that there was a statistically significant difference between the mean scores for students who utilized both teaching modalities (p=0.0001) (Bin Abdulrahman et al., 2021). In a final cross-sectional study comparing lecture with a visualization table, there was no significant difference between the two methods of learning (p=0.24) (Kausar et al., 2020). Improved Visualization of Structures In four out of fourteen studies, students expressed that the Anatomage table helped improved visualization of various organ structures (Alasmari, 2021; Anand & Singel, 2017; Fyfe et al., 2018; Washmuth et al., 2019). In a comparative study that assessed virtual dissection against traditional dissection in neuroanatomy, 89% of students stated they could visualize relative size of different parts of the brain and spinal cord better (Anand & Singel, 2017). Additionally, 90% of students found the table helped them to visualize the spatial relationships of anatomical structures better (Anand & Singel, 2017). In a case study experiment, a pregnant student only used the Anatomage table rather than participating in cadaver dissection due to their 12 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK medical needs. The students said the table enabled them to examine the anatomy in unique ways, such as viewing cross-sections of various organs and visualizing structures from different vantage points (Washmuth et al., 2019). In a cohort study, surveying usefulness of the Anatomage table for a group of students in 2013 and 2014 found that in 2014, students rated the Anatomage table more favorable and determined it was helpful for understanding relative sizes of organs (Fyfe et al., 2018). In a cross-sectional descriptive study utilizing the Anatomage table as an additional tool, 90% of students found that the tables ability to rotate the digital body and dissect in 3-D helps in visualizing anatomical structures (Alasmari, 2021). Theoretical Framework The Academic Center for Evidence-Based Practice Star Model of Knowledge Transformation (ACE Star Model) was developed by Kathleen Stevens to understand all aspects of the evidenced-based practice processes including the cycles, nature, and characteristics of knowledge (White et al., 2015). The overarching goal is knowledge transformation, which can be defined as the conversion of research findings to impact health outcomes through evidence-based care (White et al., 2015). This model explains how knowledge can be transformed through discovery research, evidence summary, translation, integration, and evaluation (Appendix C). Additionally, it depicts the relationships between various stages of knowledge transformation, from newly discovered knowledge to best practice and outcomes (Melnyk & Fineout-Overholt, 2005). The ACE Star Model emphasizes how systematic review and clinical practice guidelines can be used to implement research into practice. In the initial stages of this project, a literature review was conducted and compiled all relevant research regarding the effectiveness of the Anatomage table. Based on the literature review and recommendations found, the conductor of 13 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK the study created and implemented an action plan to educate students through use of the Anatomage table. Students then integrated their newfound knowledge into their clinical practice. Finally, student outcomes such as confidence level and knowledge of the material were evaluated. Through the execution of all five points of the ACE Star Model, this framework guided the implementation of the DNP project. Project Aims and Objectives Regional blocks are a frequently utilized method of providing anesthesia and reducing postoperative complications for patients. Students must have a thorough understanding of the anatomy involved and surrounding structures. The aim of this project is to determine whether the Anatomage table is effective in increasing students knowledge and confidence levels regarding anatomy and completing the skill. Students completed a pretest prior to attending an educational session. During the educational session, the Anatomage table was used to teach SRNAs detailed information regarding landmarks and how to identify various anatomical structures for a neuraxial block. After the instructional session, students then completed a posttest. The predicted outcome was that students developed a more in-depth understanding of how to complete neuraxial blocks and their posttest results would improve significantly compared to their pretest results. SWOT Analysis Key stakeholders involved in this project include Student Registered Nurse Anesthetists (SRNAs) at Marian University. Other stakeholders include nursing graduate faculty, College of Osteopathic Medicine faculty, medical and biomedical students who all share use of the Anatomage table. This project was carried out in Indianapolis, Indiana. A SWOT table that summarizes the analysis can be found in Appendix D. Predicted strengths for this project include 14 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK that the university owns an Anatomage table that is available for use during the day. Additionally, students can access the table and freely utilize it as a supplemental tool. There are numerous instructional resources available that can elaborate on how to operate the digital table and employ its various features. Anticipated weaknesses were that there is only one Anatomage table available, so if the machine malfunctions or experiences a technical issue then the educational intervention cannot occur. A finite number of students can be hands on with the Anatomage table at a given time, so numerous small educational sessions needed to be held to accommodate all participants of the study. Implementation of this project gave students a more thorough educational experience regarding neuraxial blocks and a visual aid to enhance their understanding. Similarly, if students found utilization of the Anatomage table beneficial, current professors may begin to implement this device as an educational and supplemental tool. Foreseen threats include limited participation from SRNAs resulting in a small sample size. Also, students may have been knowledgeable regarding the table and regional blocks prior to the educational session and due to numerous sessions being held there was a potential for increased variability between individual sessions. Project Design/Methods The primary purpose of this project was to assess anesthesia students knowledge of neuraxial anatomy and their confidence in performing a neuraxial block, along with the effectiveness of utilizing the Anatomage table in reinforcing the content. Within the literature review, various studies using the table had been completed, however there were no studies using the Anatomage table to teach central neuraxial blocks. This quality improvement design utilized an educational intervention in addition to a pretest-posttest format containing a variety of knowledge based quantitative questions, self-confidence questions and Likert scale questions. 15 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK These styles of questions were specifically chosen to mimic similar studies within the literature review (Anand & Singel, 2017; Baratz et al., 2019; Bin Abdulrahman et al., 2021; Boscolo-Berto et al., 2020; Fyfe et al., 2018; Kausar et al., 2020; Lebdai et al., 2020; Padilha et al., 2019; Tamaki et al., 2019). Population and Setting The project was conducted at a small, private university in central Indiana. The individuals participating in the project were SRNA students from the class of 2025 seeking an advanced nursing practice doctoral degree in anesthesia. This specific population was chosen because they had no previous education on neuraxial blocks or clinical experience. The population at hand had a wide array of ages ranging from their early 20s to greater than 50 and include all gender preferences. Inclusion criteria encompassed all graduate nursing students from the class of 2025 seeking a specialization in anesthesia. Exclusion criteria includes graduate nursing students seeking a specialization as a nurse practitioner and SRNA students from the class of 2024 and 2023. The class and educational session were conducted in the universitys simulation center. The conductor of the study worked closely with the simulation staff to gain access to the Anatomage table and prevent scheduling conflicts. During the project's implementation, the simulation lab was booked in advance to allow uninterrupted usage of the table during the educational intervention. Barriers for implementation included difficulty scheduling time in the simulation lab, technology issues with the Anatomage table or accessing the quiz and having poor participation from the SRNA students. Solutions to those barriers included working with simulation staff in advance, practicing with the Anatomage table prior to implementation, having paper copies of 16 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK the survey available for those with technology issues, and communicating with the SRNAs in advance regarding their schedules and availability. Measurement Instruments The pretest and posttest questionnaire consisted of knowledge questions derived from the SRNAs curriculum, specifically utilizing Nurse Anesthesia, 6th ed. (Nagelhout & Elisha, 2018). The knowledge questionnaire was tested for content validity by experienced CRNAs well versed in neuraxial blocks (Appendix E). Additionally, a modified version of the National League for Nursing Student Satisfaction and Self-Confidence Tool (NLN, n.d.) was utilized to assess students confidence in identifying anatomy and completing a neuraxial block in the clinical setting (Appendix F). The control groups questionnaire was identical to the intervention groups pretest. Data Collection Procedures Recruitment occurred through the prospective students university email, along with scheduling information. A brief overview of the study, the Anatomage table and the benefits of participating in the project was shared with students. The pretest was also distributed in the recruitment email to ensure students completion before attending the educational session. A quick-response (QR) code was made available for students to take the posttest immediately afterwards. A separate QR code was used for the control groups questionnaire. The pretest and posttest for participants were linked via the last four digits of the participants student identification number (ID). The conductor did not have access to identify students based on their student ID. The password protected Qualtrics website was used to complete the survey and store the raw data. The raw data was not accessible by anyone other than the conductor. The data was only presented in aggregated form. A password protected excel spreadsheet was used to compare 17 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK and analyze the results of the raw data. The excel document will be stored on the conductors password protected computer, and the data will be preserved for a maximum of two years then securely discarded. Data Analysis The efficacy of the project relies on data analysis. Data analysis provides a statistical measurement that ensures the effectiveness of a project (White et al., 2016). Nonparametric ttests were chosen over parametric t-tests due to the studys small sample size (Nahm, 2016). A nonparametric paired t-test was used to compare pretest and posttest scores of students who participated in the entire study and determine the significance of the scores. A nonparametric independent t-test was also utilized to compare the posttest scores between students who participated and students who did not participate in the study. Ethical Considerations/protection of human subjects The Marian Internal Review Board (IRB) exemption (S23.151) was received on April 10, 2023, before the project's implementation. The IRB determination form can be found in Appendix G. Each participant used a unique ID number to maintain confidentiality of identifiable information and responses. There were no ethical concerns, or risk of physical or emotional injury to participants. Also, participants had the option to withdraw from the project at any point during the study. Results In line with the objective to assess the effectiveness of the Anatomage table in SRNA education, 28 first-year Marian SRNAs participated in this study to completion. 21 students participated in the intervention group by taking the pretest, attending the educational 18 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK intervention, and completing the posttest. Whereas the control group had 7 students who solely took the control assessment. Knowledge and Self-Confidence with Current learning The pretest for the intervention group and control test for the control group were identical. They consisted of 10 knowledge questions and 4 self-confidence questions. The posttest for the intervention group consisted of 10 knowledge questions, 2 satisfaction questions, 6 confidence questions and 2 Anatomage table opinion questions. All questions were analyzed separately by their reported levels of agreement and compared amongst groups. Please see Appendix H to view Tables 6-15. Student Knowledge Students were given a 10-question knowledge test on neuraxial anatomy. These were single-response multiple choice questions. Students in the intervention group took a knowledge test before and after the educational session. Their pretest scores ranged from 40 to 100%, with a mean of 61.9% (SD: 1.17). The intervention groups post-test scores ranged from 60 to 100%, with a mean score of 81.4% (SD: 0.91). A Wilcoxon Signed-Rank test concluded that the intervention groups posttest was statistically significant (p =.001) when compared to their pretest. The control groups knowledge test scores ranged from 60 to 90%, with a mean score of 72.9% (SD: 1.11). A Mann-Whitney U test concluded the control groups test scores were not statistically significant (U = 41, p = 0.073) when compared to the intervention groups posttest scores. Intervention group Self-Confidence in Learning (Pre vs. Post-Test) To determine self-confidence, students reported levels of personal satisfaction on a 5point Likert scale that ranged from 1 to 5 (1= strongly disagree and 5= strongly agree). The 19 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK range of self-confidence mean scores for the pre-test was 2.62 to 3 (Table 1). The range of selfconfidence mean scores for the post-test was 4.05 to 4.33. The results of a Wilcox Signed-Rank test concluded that the intervention group had more self-confidence in learning during the posttest than the pretest. Each individual question in the subscale was statistically significant (p=0.001). Additionally, the summative self-confidence score was higher in the posttest results (16.81) than the pretest (11.38). However, the difference in summed self-confidence was not statistically significant (p = 0.125). Table 1 Intervention Groups Results of 4-Items to Measure Self-Confidence Intervention Intervention Mean Item Group Pre-Test Group Post-Test p-Value Difference Mean (SD) Mean (SD) Self-Confidence 5 3.00 (0.83) 4.24 (0.62) +1.24 0.001 Self-Confidence 6 2.76 (0.83) 4.19 (0.60) +1.43 0.001 Self-Confidence 7 3.00 (0.89) 4.33 (0.66) +1.33 0.001 Self-Confidence 8 2.62 (0.81) 4.05 (0.87) +1.43 0.001 Summed Confidence 11.38 (0.19) 16.81 (0.12) +5.43 0.125 *Note. Using Wilcoxon Signed-Rank test, statistically significant change at p <0.05. Both groups Self-Confidence in Learning (Control group vs. Intervention) To determine self-confidence, students reported levels of personal satisfaction on a 5point Likert scale that ranged from 1 to 5 (1= strongly disagree and 5= strongly agree). The selfconfidence range of mean scores for the control group was 2.57 to 3.43 (Table 2). Whereas the self-confidence range of mean scores for the post-test was 4.05 to 4.33. The results of a MannWhitney U test concluded that the intervention group had more self-confidence in learning after the educational session compared to the control group. Each individual question in the subscale was statistically significant (p < .05). Additionally, the summative self-confidence score was higher in the intervention groups post-test (16.81) compared to the control group (11.38). The 20 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK difference in both groups summed self-confidence was statistically significant (U= 0, p = 0.029). Table 2 Both Groups Results of 4-Items to Measure Self-Confidence Item Control Group Test Mean (SD) Intervention Group Post-Test Mean (SD) Mean Difference Self-Confidence 5 3.43 (0.79) 4.24 (0.62) +0.81 Self-Confidence 6 3.00 (0.82) 4.19 (0.60) +1.19 Self-Confidence 7 3.29 (0.76) 4.33 (0.66) +1.05 Self-Confidence 8 2.57 (0.54) 4.05 (0.87) +1.48 Summed Confidence 8.43 (0.38) 16.81 (0.12) +8.38 *Note. Using Mann-Whitney U test, statistically significant change at p <0.05. p-Value 0.020 0.002 0.005 0.001 0.029 Interventional Group Self-Confidence Descriptive Statistics The interventional groups mean self-confidence scores for the pretest ranged between 2.62 to 3.00 (Table 3). With a median score of a 3 or neither agree or disagree in all items. Additionally, the range for all questions was between 1-4, with no students selecting a 5 or strongly agree in relation to confidence. On average, students did not feel confident or felt neutral regarding their knowledge and skill in placing neuraxial blocks prior to the intervention. Table 3 Interventional Groups Self-Confidence Pretest Assessment Descriptive Statistics Item Mean Std. Deviation Median Variance Range Self-Confidence 5 3.00 0.837 3 0.70 1-4 Self-Confidence 6 2.76 0.831 3 0.69 1-4 Self-Confidence 7 3.00 0.894 3 0.80 1-4 Self-Confidence 8 2.62 0.805 3 0.65 1-4 n=4 The interventional groups self-confidence posttest scores increased in all categories, showing a positive improvement after using the Anatomage table. Their mean scores ranged 21 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK from 4.048 to 4.857 (Table 4). This is a substantial improvement from their pre-test mean scores of 2.62 to 3.00. The median scores also increased from a 3 in all questions, to 4s and 5s. For self-confidence questions 1, 2, and 10, the range was 1-10. Only one student marked a 1 or strongly disagree for these questions. All other students marked 4 or 5 (agree or strongly agree) (See Appendix H). The range also increased from 1-4 to 1-5 with more students choosing strongly agree for their confidence levels. Table 4 Interventional Groups Self-Confidence Posttest Assessment Descriptive Statistics Item Self-Confidence 1 Self-Confidence 2 Self-Confidence 3 Self-Confidence 4 Self-Confidence 5 Self-Confidence 6 Self-Confidence 7 Self-Confidence 8 Self-Confidence 9 Self-Confidence 10 n=21 Mean 4.619 4.667 4.286 4.762 4.238 4.190 4.333 4.048 4.857 4.667 Std. Deviation 0.921 0.913 0.463 0.436 0.625 0.602 0.658 0.865 0.359 0.913 Median 5 5 4 5 4 4 4 4 5 5 Variance 0.85 0.83 0.21 0.19 0.39 0.36 0.43 0.75 0.13 0.83 Range 1-5 1-5 4-5 4-5 3-5 3-5 3-5 2-5 4-5 1-5 Control Group Self-Confidence Descriptive Statistics The control groups mean and median scores were comparable to the interventional groups pre-test scores. The control groups mean scores ranged from 2.57 to 3.43 (Table 5). Their median scores were mostly 3s (neither disagree or agree) and a 4 (agree). The range varied anywhere between 2-3 and 2-4. With no students marking a 1 (strongly disagree) or 5 (strongly agree) regarding their confidence levels. However, the control groups selfconfidence means and median scores were noticeably lower than the interventional groups posttest scores, which had mean scores ranging from 4.048 to 4.857 and median scores in the 4s and 5s (agree or strongly agree). 22 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK Table 5 Control Groups Self-Confidence Assessment Descriptive Statistics Item Self-Confidence 5 Self-Confidence 6 Self-Confidence 7 Self-Confidence 8 n=7 Mean 3.43 3.00 3.29 2.57 Std. Deviation 0.787 0.816 0.756 0.535 Median 4 3 3 3 Variance 0.62 0.67 0.57 0.29 Range 2-4 2-4 2-4 2-3 Discussion of Findings Our findings of increased knowledge and satisfaction align with Baratz et al. (2019), Anand & Singel (2017), and Fyfe et al. (2018), who also noted enhanced learning outcomes with similar digital tools. The SRNAs that took part in the experimental group had improved knowledge and satisfaction with learning methods compared to the control group. 80.95% of participants strongly agree and 14.29% agree the Anatomage table should be incorporated into the SRNA curriculum. Similarly, 76.19% of participants strongly agree and 19.05% agree the Anatomage table was motivating and helped them learn. One student did skew the data since they marked these questions as a 1 or strongly disagree but it is possible the student answered the questions without reading the scale correctly. Additionally, 100% of participants felt that the Anatomage table was a helpful tool, with 85.71% of participants marking strongly agree and 14.29% marking agree. Overall students felt strongly that the Anatomage table is a great resource to utilize in the CRNA program. The control group had a high average score on the knowledge test. They also had some high scores on the confidence scores but not as high as the interventional post-group since none of the students marked a 5 or strongly agree for the confidence levels. This could be due to their data being collected one week after the intervention group took part in the study. The project was implemented the same week as the students Anesthesia Principles neuraxial 23 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK lectures. Since the control group already had been exposed to the class material for a week longer than the intervention group, it is possible that they may have already spent time learning some of the material. Additionally, increased exposure to the material may have improved their knowledge and self-confidence. However, the control group did not feel as if they had mastered the steps to perform a spinal with 57.14% of participants marking neither agree or disagree and 42.86% marking disagree. To conclude, students who attended the educational intervention with the Anatomage table had higher level of knowledge and self-confidence compared to students who did not attend. Additionally, students felt like the Anatomage table was useful in enhancing their understanding of neuraxial anatomy and blocks and would like the Anatomage table to be incorporated into the curriculum. Strengths and Limitations Some of the strengths of this project were the Anatomage table was readily available and numerous resources were accessible for the investigator to learn how to operate the table. Due to the project's nature, resource availability and lack of monetary requirement, this project would be easy to replicate or build upon as a legacy project. Additionally, the project was intentionally implemented the same week as the students neuraxial lecture to serve as a supplementation of material and encourage student participation. A limitation of this project was the small sample size. Only first-year Marian SRNA students were enlisted to take part due to convenience, lack of access to students from other programs, and their limited knowledge surrounding the topic at hand. Due to the specificity of the population, the data results cannot be generalized to SRNAs at other institutions. Additionally, due to the small sample size, only non-parametric statistics could be calculated. 24 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK Finally, there may be an increased variability of effectiveness due to many sessions being held and slight variations in the educational session due to it not being completely scripted. While the results are promising, they should be interpreted with caution due to the small sample size and the potential influence of coinciding lectures. Conclusion The results of the study demonstrated that the Anatomage table significantly improves knowledge and self-confidence among first-year Marian SRNAs in neuraxial block techniques. Additionally, students agreed the use of the Anatomage table was a beneficial and helpful tool for enhancing their understanding of neuraxial blocks. This study contributes to our understanding of how innovative educational technologies can be effectively integrated into specialized nursing programs. However, more research is needed to assess the long-term effects of digital tools like the Anatomage table on SRNA education across diverse educational settings. In conclusion, these findings suggest the benefit of integrating advanced digital tools in nursing education curricula to improve learning outcomes and subsequently enhance patient care. 25 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK References Alasmari, W. A. (2021, November 11). Using Anatomage in learning anatomy: AMEP. Advances in Medical Education and Practice. Retrieved from https://doi.org/10.2147/AMEP.S324520 Albrecht, E. & Chin, K.J. (2020). Advances in regional anesthesia and acute pain management: A narrative review. Anesthesia, 75(S1), 101-110. https://doi.org/10.1111/anae.14868 Anand, M. K., & Singel, T. C. (2017). A comparative study of learning with "Anatomage" virtual dissection table versus traditional dissection method in neuroanatomy. Indian Journal of Clinical Anatomy and Physiology, 4(2), 177180. https://doi.org/10.18231/2394-2126.2017.0044 Baratz, G., Wilson-Delfosse, A. L., Singelyn, B. M., Allan, K. C., Rieth, G. E., Ratnaparkhi, R., Jenks, B. P., Carlton, C., Freeman, B. K., & Wish-Baratz, S. (2019). Evaluating the Anatomage Table compared to cadaveric dissection as a learning modality for gross anatomy. Medical Science Educator, 29(2), 499506. https://doi.org/10.1007/s40670-01900719-z Bin Abdulrahman, K. A., Jumaa, M. I., Hanafy, S. M., Elkordy, E. A., Arafa, M. A., Ahmad, T., & Rasheed, S. (2021). Students' perceptions and attitudes after exposure to three different instructional strategies in applied anatomy. Advances in Medical Education and Practice, 12, 607612. https://doi.org/10.2147/AMEP.S310147 Boscolo-Berto, R., Tortorella, C., Porzionato, A., Stecco, C., Picardi, E. E. E., Macchi, V., & De Caro, R. (2021). The additional role of virtual to traditional dissection in teaching anatomy: A randomized controlled trial. Surgical and Radiologic anatomy: SRA, 43(4), 469479. https://doi.org/10.1007/s00276-020-02551-2 26 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK Brown, J., Stonelake, S., Anderson, W., Abdulla, M., Toms, C., Farfus, A., & Wilton, J. (2015). Medical student perception of Anatomage a 3-D interactive anatomy dissection table. International Journal of Surgery, 23. https://doi.org/10.1016/j.ijsu.2015.07.053 Fyfe, S., Fyfe, G., Dye, D., & Radley-Crabb, H. (2018). The Anatomage Table: Differences in student ratings between initial implementation and established use. Focus on Health Professional Education: A Multi-Professional Journal, 19(2), 4152. https://doi.org/10.11157/fohpe.v19i2.215 Kausar, T., Chandio, S., Quddus, I., Qureshi, G. S., Baloch, Z. H., & Pario, A. (2020). Effectiveness of teaching with visualization table in comparison to traditional lecture in anatomy department, Jinnah Sindh Medical University. Journal of the College of Physicians and Surgeons--Pakistan: JCPSP, 30(10), 10741077. https://doi.org/10.29271/jcpsp.2020.10.1074 Lebdai, S., Mauget, M., Cousseau, P., Granry, J. C., & Martin, L. (2021). Improving academic performance in medical students using immersive virtual patient simulation: A randomized controlled trial. Journal of Surgical Education, 78(2), 478484. https://doi.org/10.1016/j.jsurg.2020.08.031 Li, J., Li, X., Gu, L., Zhang, R., Zhao, R., Cai, Q., Lu, Y., Wang, H., Meng, Q., & Wei, H. (2019). Effects of simulation-based deliberate practice on nursing students' communication, empathy, and self-efficacy. The Journal of Nursing Education, 58(12), 681689. https://doi.org/10.3928/01484834-20191120-02 Martn, J. G. (2018). Possibilities for the use of Anatomage (the anatomical real body-size table) for teaching and learning anatomy with the students. Biomedical Journal of Scientific & Technical Research, 4(4). https://doi.org/10.26717/bjstr.2018.04.0001094 27 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK Melnyk, B. M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & healthcare: A guide to best practice. Lippincott Williams & Wilkins. Nahm F. S. (2016). Nonparametric statistical tests for the continuous data: the basic concept and the practical use. Korean journal of anesthesiology, 69(1), 814. https://doi.org/10.4097/kjae.2016.69.1.8 Nagelhout, J. J., & Elisha, S. (Eds.). (2018). Nurse anesthesia (6th ed.). Elsevier. National League for Nursing (NLN) n.d.. Descriptions of available instruments. Retrieved from http://www.nln.org/professional-development-programs/research/toolsandinstruments/descriptions-of-available-instruments Owolabi, J., Ojiambo, R., Seifu, D., Nishimwe, A., Masimbi, O., Okorie, C. E., Ineza, D., & Bekele, A. (2022). African medical educators and anatomy teachers' perceptions and acceptance of the Anatomage table as an edtech and innovation: A qualitative study. Advances in medical education and practice, 13, 595607. https://doi.org/10.2147/AMEP.S358702 Padilha, J. M., Machado, P. P., Ribeiro, A., Ramos, J., & Costa, P. (2019). Clinical virtual simulation in nursing education: Randomized controlled trial. Journal of Medical Internet Research, 21(3), e11529. https://doi.org/10.2196/11529 Tamaki, T., Inumaru, A., Yokoi, Y., Fujii, M., Tomita, M., Inoue, Y., Kido, M., Ohno, Y., & Tsujikawa, M. (2019). The effectiveness of end-of-life care simulation in undergraduate nursing education: A randomized controlled trial. Nurse Education Today, 76, 17. https://doi.org/10.1016/j.nedt.2019.01.005 Tirelli, G., de Groodt, J., Sia, E., Belgrano, M. G., Degrassi, F., Boscolo-Rizzo, P., Cova, M. A., 28 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK & Marcuzzo, A. V. (2021). Accuracy of the Anatomage Table in detecting extranodal extension in head and neck cancer: A pilot study. Journal of Medical Imaging (Bellingham, Wash.), 8(1), 014502. https://doi.org/10.1117/1.JMI.8.1.014502 Washmuth, N. B., Cahoon, T., Tuggle, K., & Hunsinger, R. N. (2020). Virtual dissection: Alternative to cadaveric dissection for a pregnant nurse anesthesia student. Health Professions Education, 6(2), 247-255. White, K. M., Dudley-Brown, S., & Terhaar, M. F. (Eds.). (2015). Translation of evidence into nursing and health care, second edition. Springer Publishing Company, Incorporated. 29 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK Appendix A Prisma Flow Diagram Screening Identification Identification of studies via databases and registers Records identified from: CINAHL (n = 68) PubMed (n = 54) Records removed before screening: Duplicate records removed (n =45) Records removed for other reasons (n =35) Records screened (n =42) Records excluded (n = 15) Reports sought for retrieval (n=27) Records not retrieved (n = 2) Included Reports assessed for eligibility (n =25) Studies included in literature review (n =14) Reports excluded: (n=11) Study did not primarily investigate virtual dissection, digital anatomy, digital learning or cadaver lab 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.prismastatement.org/ 30 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK Appendix B Literature Review Matrix Citation Research Design & Level of Evidence (Alasmari, 2021) Crosssectional descriptive Study, Level VI (Anand & Singel, 2017) Randomized cross sectional prospective study, Level IV (Baratz et al., 2019) Randomized Crosssectional study, Level III Population / Sample size n=x Major Variables Instruments / Data collection Medical students in the Department of Anatomy at College of Medicine, Umm Al-Qura University; N=78 1st year MBBS class of Gujarat Adani Institute of Medical Sciences; n=122 Independent: Anatomage table Electronic questionnaire with 6 questions Independent: Anatomage virtual dissection table, direct exposure to specimens and performed dissection Pretest and posttest with 20 single correct answer type Multiple Choice Questions. Likerts 5-point scale First-year medical student volunteers who had previously dissected thorax and abdomen; N=16 Independent: Anatomage table, cadaveric dissection Dependent: Pelvis/perineum and musculoskeletal system Likert scale surveys before and affect each scheduled dissection session and a 5-question multiple choice post-lab quiz Results 81% of the students preferred using 3-D Anatomage as an additional tool to cadaveric dissected specimens in learning anatomy. 90% of the participating students believed that Anatomage helps in visualizing the body system due to the ability to rotate the digital body and accordingly provided a better understanding of Anatomy. There was no statistically significant difference found between learning with the Anatomage table compared to learning with traditional dissection (p=0.0979). 51% of Students agreed that the virtual dissection table helped them to understand the topic better. 90% found it helped them to visualize relations of different parts better. 79% agreed it enhanced their learning experience No difference was found between the two modalities in pelvis/perineum. In MSK, the Anatomage group had a significantly higher average quiz score than the control group (p=0.03). The pre- and post-lab qualitative surveys indicated that students who learned via the Anatomage table were more excited both before and after the labs and believed they learned more. 31 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK (Bin Abdulrahman et al., 2021) Randomized Crosssectional study, Level II First year college of medicine at Imam Mohammad Ibn Saud Islamic University N=211 Independent: Anatomage table, Plastinated specimens, both Objective structed practical examination with ten practical questions Structured questionnaire with 15 Likert-type scale questions (BoscoloBerto et al., 2020) Randomized controlled trial, Level II Independent: Textbook consultation, virtual dissection Pre-test with 10 multiple choice questions Posttest with four questions (Fyfe et al., 2018) Prospective Cohort, Level IV Second year medical students who took part in the elective anatomic dissection course; N=23 First year human biology students at Curtin University 2013 n = 333 2-14 n = 329 Dependent: use of a smart phone, tablet, anatomy apps Survey with Likert scales, rating scales, text responses, and radio buttons (Kausar et al., 2020) Randomized Crosssectional study, Level II First year Bachelor of Dental Surgery Students; n=50 Independent: traditional lecture, Sectra visualization table Multiple choice question test with 10 questions Likert scale (Lebdai et al., 2020) Prospective randomized controlled study, Level II Fourth Year Angers School of Medicine Semester 1 (n=38) Semester 2 (n=47) Independent: Immersive Virtual Patient Simulation group trained on 3 different virtual clinical cases Standard posttest which included a clinical case with multiple choice questions and 5-point Likert scale (Li et al., 2019). Randomized controlled trial, Level II First year undergraduate students (n=132) Independent: Simulation-based deliberate practice The Communication Skills Assessment Scale, the Jefferson Scale of Empathy-Health The combined method was significantly different from other methods. No significant difference between Anatomage and plastinated models Higher and positive students' attitudes in favor of both models teaching compared to Anatomage table and plastinated model teaching alone Better overall test performance was detected for the group that participated in virtual dissection (p=0.06) Medical students who participated in virtual dissection were over 3 times more likely to report a positive outcome at the postdissection test Significant increase in the average rating for the usefulness of the Anatomage table (p=0.022). In 2014, respondents rated the Anatomage table more favorably than in 2013 (p=0.022) Rated most helpful for understanding relative sizes of organs but least helpful for using correct anatomical terminology Statistically non-significance between the two groups (p=0.24) All students showed strong positive response towards the use of Sectra For 7/10 questions, more than 60% expressed strong agreement Students from the IVPS group achieved significantly higher grades in semester 2 than in semester 1(p = 0.0020. Students from the IVPS group in both semesters 1 and 2 achieved significantly higher grades than either of the control groups from semesters 1 and 2 (p < 0.003). Based off the clinical communication ability scale scores, there were remarkable improve- 32 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK which included educational videos and discussions, scenario-based simulations, reflections on their communication skills and empathy ability and a group chat to share communication videos, skills, and knowledge. Dependent: Anatomage-user institution, nonuser institution Professionals, and the General Self-Efficacy Scale. ments in the experimental group, with a statistically significant difference (p < .01). During the posttest, students empathy scores had noteworthy improvements in the experimental group, with a statistically significant difference. Students self-efficacy scores significantly improved in the posttest of the experimental group (p = .003). Focused Group Discussion guided questions; In-depth Interview guided questions Most recurring opinion was the Anatomage table could only be a complementary teaching tool to cadavers, it cant replace real-life experience with cadavers. Supplement for cadaveric dissection, not a substitute. Has potential to integrate both laboratory and classroom experience. Solve shortages of a cadaver. Students who participated in the clinical virtual simulation had statistically significant differences in knowledge retention after the intervention (p=.001), knowledge retention 2 months later (p=.02), and in learning satisfaction (p<.001). These students also presented with better outcomes in knowledge retention and learning satisfaction than students who did not participate in the clinical virtual simulation. In the post-test, the mean knowledge score had significantly increased for the simulation group (p=0.000). The mean physical assessment score of the simulation group had significantly increased (p=0.000) at the post-test. (Owolabi et al., 2022) Qualitative Study, Level VI Anatomy teachers from 11 African Countries. N=79 (Padilha et al., 2019) Randomized controlled trail, Level II Second year Portuguese nursing students (N=42) Independent: clinical virtual simulator Dependent: Knowledge and clinical reasoning Pretest and 2 posttests (one after the intervention, and one 2 months later) Knowledge assessments with T/F questions and multiple-choice, 10point Likert scale for satisfaction levels, 5-point Likert scale for selfefficacy (Tamaki et al., 2019) Randomized controlled study, Level II Third year Japanese nursing students (n=38) Independent: End of Life care simulation Pre and Post test Knowledge questionnaire with 10 multiple-choice questions Objective Structured Clinical Evaluation with a physical assessment examination station 33 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK (Tirelli et al., 2021) Blind prospective study on a retrospective cohort, Level IV Head and neck squamous cell carcinoma treated in their department between 2012 and 2018 N=66 Dependent: lymph nodal metastases, size of the lymph nodes (Washmuth et al., 2019) Case Study design, Level IV Graduate Nurse anesthesia students (one who is pregnant) N=25 Independent: cadaver dissection, Anatomage table and a psychological care examination to evaluate skill performance. Radiologist reviewed the reconstructions blinded to lymph node size and pENE status, also asked to express a judgment as to whether capsular involvement was present, results compared with the CT, MRI, and histology reports to determine accuracy of Anatomage table. Four written and four practical exams Also, open-ended qualitative data The mean score for psychological care was also significantly greater (p=0.000) at the post-test in the simulation group. For lymph nodes > 15 mm on CT, Anatomage table 3-D reconstructions identified extracapsular invasion with a sensitivity of 100%, a specificity of 75%, a positive predictive value of 86%, and a negative predictive value of 100%. The Anatomage table enabled detection of all 30 patients who were pENE+. Had a higher percentage of concordance with histopathological examination (90%) than the CT and MRI scans The Anatomage table grades are the same or higher than the cadaver dissection group median values for 3 exams and lower on one exam. In every test, the Anatomage table grade falls within the Interquartile range 34 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK Appendix C The Academic Center for Evidence-Based Practice Star Model of Knowledge Transformation Knowledge discovery Evaluation ACE Star Model Integration into Practice Evidence Summary Translation Into Practice White, K. M., Dudley-Brown, S., & Terhaar, M. F. (Eds.). (2015). Translation of evidence into nursing and health care, second edition. Springer Publishing Company, Incorporated. 35 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK Appendix D SWOT Analysis Strengths Weaknesses Availability of Anatomage table Ample resources to educate how to utilize the table Cost effective Easily reproducible Only one Anatomage table Risk for technological issues Small sample size Decreased generizability Opportunities Threats Students visualize anatomy from a new perspective Strengthens futrure curriculum by incorporating Anatomage table Improves SRNA's care of patients Lack of participation from students due to interest or time Students may be knowledgeable prior to educational session Multiple sessions increases data variability 36 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK Appendix E Knowledge Assessment Questionnaire 1. The spinal cord ends at what level in an adult? a. L2 b. S1 c. L3 d. T10 2. What vertebral level does the intercristal line correlate with? a. L2 b. T12 c. L4 d. C6 3. Which components of the spinal cord are associated with kyphosis? a. Cervical b. Thoracic c. Lumbar d. Cranial 4. What is the average distance from the skin to the lumbar epidural space when using a midline approach? a. 5 mm b. 2 cm c. 5 cm d. 7 cm 5. When placing a traditional midline neuraxial anesthetic, which is the correct order of structures that are pierced with the needle? a. Skin -> Anterior Longitudinal Ligament -> Interspinous ligament -> Posterior Longitudinal Ligament b. Skin -> Ligamentum Flavum -> Anterior Longitudinal Ligament -> Interspinous ligament c. Skin -> Interspinous ligament -> Supraspinous Ligament -> Posterior Longitudinal Ligament d. Skin-> Supraspinous Ligament -> Interspinous Ligament -> Ligamentum Flavum 6. Where are spinal blocks administered? a. Epidural Space b. Subdural Space c. Epiarachnoid Space d. Subarachnoid Space 7. Cervical and thoracic vertebrae have spinous processes that are angled in a caudal direction. a. True 37 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK b. False 8. As the pencil-point needle tip passes through the ________, the CRNA may feel a pop or click sensation. a. Dura Mater b. Arachnoid Mater c. Pia Mater d. Ligamentum Flavum 9. Approximately how much cerebrospinal fluid is present in the spinal canal? a. 15-30 mLs b. 30-80 mLs c. 90-120 mLs d. 100-150 mLs 10. Which ligament is located in between the lamina of the vertebrae? a. Supraspinous Ligament b. Interspinous Ligament c. Ligamentum Flavum d. Posterior longitudinal Ligament 38 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK Appendix F Student Satisfaction and Self-confidence assessment for the Pretest and Control test Student Satisfaction and Self-confidence assessment for the Posttest 39 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK Appendix G 40 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK Appendix H Table 6 Helpfulness of Teaching Methods Used in Simulation Helpfulness of Teaching Methods Used Post-Test Experimental Group Strongly Disagree Disagree Undecided Agree Strongly Agree n % 1 0 0 4 16 4.76 0.00 0.00 19.05 76.19 Table 7 Anatomage table used in this simulation were motivating and helped me to learn Motivating and Helpful Post-Test Experimental Group Strongly Disagree Disagree Undecided Agree Strongly Agree n % 1 0 0 4 16 4.76 0.00 0.00 19.05 76.19 n % 0 0 0 15 6 0.00 0.00 0.00 71.43 28.57 Table 8 Confidence in Mastering the Content of the Simulation Activity Confidence in Mastering the Content Post-Test Experimental Group Strongly Disagree Disagree Undecided Agree Strongly Agree Table 9 Confidence that this simulation covered critical content necessary for the mastery of neuraxial blocks. 41 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK Confidence that this simulation covered critical content Post-Test Experimental Group Strongly Disagree Disagree Undecided Agree Strongly Agree n % 0 0 0 5 16 0.00 0.00 0.00 23.81 76.19 Table 10 Confidence in developing the skills and obtaining the required knowledge to perform neuraxial blocks in a clinical setting Confidence in Developing skills and Obtaining Knowledge Pre-Test Experimental Group Strongly Disagree Disagree Undecided Agree Strongly Agree Post-Test Experimental Group Strongly Disagree Disagree Undecided Agree Strongly Agree Control Group Strongly Disagree Disagree Undecided Agree Strongly Agree n % 1 4 10 6 0 4.76 19.05 47.62 28.57 0.00 0 0 2 12 7 0.00 0.00 9.52 57.14 33.33 0 1 2 4 0 0.00 14.29 28.57 57.14 0.00 n % 1 7 4.76 33.33 Table 11 Confidence in Knowledge Confidence in Knowledge Pre-Test Experimental Group Strongly Disagree Disagree 42 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK Undecided Agree Strongly Agree Post-Test Experimental Group Strongly Disagree Disagree Undecided Agree Strongly Agree Control Group Strongly Disagree Disagree Undecided Agree Strongly Agree 9 4 0 42.86 19.05 0.00 0 0 2 13 6 0.00 0.00 9.52 61.9 28.6 0 2 3 2 0 0.00 28.57 42.86 28.57 0.00 n % 1 5 8 7 0 4.76 23.81 38.10 33.33 0.00 0 0 2 10 9 0.00 0.00 9.52 47.62 42.86 0 1 3 3 0 0.00 14.29 42.86 42.86 0.00 Table 12 Confidence in identifying pertinent anatomical landmarks Confidence in identifying landmarks Pre-Test Experimental Group Strongly Disagree Disagree Undecided Agree Strongly Agree Post-Test Experimental Group Strongly Disagree Disagree Undecided Agree Strongly Agree Control Group Strongly Disagree Disagree Undecided Agree Strongly Agree 43 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK Table 13 Confidence in mastery of steps to perform a spinal Confidence in mastery of steps to perform a spinal Pre-Test Experimental Group Strongly Disagree Disagree Undecided Agree Strongly Agree Post-Test Experimental Group Strongly Disagree Disagree Undecided Agree Strongly Agree Control Group Strongly Disagree Disagree Undecided Agree Strongly Agree n % 1 9 8 3 0 4.76 42.86 38.10 14.29 0.00 0 1 4 9 7 0.00 4.76 19.05 42.86 33.33 0 3 4 0 0 0.00 42.86 57.14 0.00 0.00 n % 0 0 0 3 18 0.00 0.00 0.00 14.29 85.71 n % Table 14 Anatomage table was a helpful resource Anatomage table was a helpful resource Post-Test Experimental Group Strongly Disagree Disagree Undecided Agree Strongly Agree Table 15 Anatomage table should be incorporated into curriculum Anatomage table should be incorporated into curriculum Post-Test Experimental Group 44 EFFECTIVENESS OF UTILIZING THE ANATOMAGE TABLE TO TEACH A REGIONAL BLOCK Strongly Disagree Disagree Undecided Agree Strongly Agree 1 0 0 3 17 4.76 0.00 0.00 14.29 80.95  ...

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