Transition to wellness: developing a telehealth wellness program to address student fieldwork challenges during the COVID-19 pandemic

Introduction

Throughout the lifespan, people experience transitional periods that impact their everyday activities and occupations. A transition is a passage, evolution, development or abrupt change that leads to movement from one life state, stage or place to another (1). Transitions are categorized as the process of a person internalizing and adapting to changes in circumstance, role, or responsibility (2). When disease, injury or other life trauma interrupt the naturally occurring process of life transitions it often becomes necessary to develop new or additional skills and extra planning to move successfully through the culturally defined stage of life (1). Transitions can cause people a great deal of stress, uncertainty, and general imbalance, which can affect their health and well-being. Many people are experiencing this due to the COVID-19 pandemic as the pervasive impact of the COVID-19 pandemic effects all aspects of daily life, at an individual, community and societal level.

The impact of the COVID-19 pandemic on both healthcare settings and healthcare student’s academic progression led to the need to develop the Transition to Wellness Virtual Program at the University of Alabama at Birmingham (UAB) to allow students to continue to progress towards graduation during lockdowns and limited fieldwork opportunities. This would be a student-led, online program focused on supporting people through life transitions, as a result of the pandemic, towards wellness. The program would prove to be invaluable at a time when fieldwork, an integral element of occupational therapy (OT) education, were being curtailed or halted due to lockdowns and the risk of student presence in healthcare settings.

This paper describes the impact that the unpredictable nature of the transition, resulting from the pandemic, and the resultant process of developing a program to support people in the community. The process from the selection of an occupation-based theoretical model of practice, to the delivery of support to individuals in promoting health and well-being during this extended period of occupational imbalance, and also how this program provided student fieldwork opportunities at a time when programs are struggling to support the academic progression of their students is documented. This model has the potential to be replicated in other programs across the country.

Occupational disruption during a global pandemic

On March 11, 2020 the World Health Organization declared a pandemic due to a global outbreak of COVID-19, an infectious disease caused by the coronavirus (3). While this declaration set in motion preparedness and response plans all around the world these were primarily aimed at “flattening the curve” to reduce new cases of COVID-19 and little attention was focused on the resultant restriction of people’s roles, routines and ability to take care of themselves, enjoy leisure pursuits or productively contribute to their communities that resulted from the inevitable disruption to daily life (4)

Humans are occupational beings. Occupation has been defined as the “activities that people engage in throughout their daily lives to fulfill their time and give life meaning. Occupations involve mental abilities and skills and may or may not have an observable physical dimension” (5). Zemke and Clark stated that occupations are “chunks of daily activity that can be named in the lexicon of the culture” (6). Occupation is believed to give life meaning and organize behavior, as well as be a critical determinant of health and well-being with therapeutic potential (7,8).

While some occupations may be easily adjusted or omitted, individuals can experience occupational disruption if they cannot participate in the day-to-day occupations that make up life as they know it (7). Nizzero et al. (9) advocated the importance of understanding what happens when individuals are unable to participate in meaningful occupations, even transiently or temporarily, referring to this state of impaired participation as occupational disruption (4). To adapt during a pandemic, individuals needed to change what they do to respond to their ‘new’ environment to maintain their occupational performance (4).

Understanding this, it becomes clear that the COVID-19 pandemic caused widespread occupational disruption and occupational imbalance by precipitating unexpected changes for many people around the world. People were forced to adapt to a “new normal” and transition into new roles and routines, such as working from home, online schooling, and social distancing. For OT students, this meant they were unable to return to a traditional classroom, and they had to adjust to participating in their education through a virtual platform. Compounding this, fieldwork sites were unable to accommodate students, and universities were required to withdraw students from existing fieldwork placements. Seemingly overnight, the immediate future of fieldwork experiences became uncertain, and many students faced the possibility that their education, graduation, and progression into their careers would be delayed.

The Department of Occupational Therapy at the UAB, like many programs nationally, needed to figure out how to provide students with fieldwork opportunities during this constantly changing situation. Inspired by a conversation with colleagues from the Department of Occupational Therapy at the University of Indianapolis, the faculty at UAB proposed the idea of creating a student-led health and wellness program delivered through a virtual platform, with a focus on well-being during times of transition. This program would serve as an opportunity for students to experience wellness and telehealth, both emerging areas of OT practice, for their Level II fieldwork placement. According to the American Occupational Therapy Association, the need for health and wellness services will increase in coming years, so it is vital that students learn how OT can contribute to this area of practice (10).

OT practitioners are well-suited to address the needs of individuals and groups experiencing occupational disruption or occupational imbalance as they understand how the interactions between roles, routines, daily occupations, and environments impact health and well-being (10). The profession supports people in adapting and organizing occupations and routines to promote a healthy lifestyle. Because of this, they are uniquely equipped to assist others in adjusting to life transitions in a healthy manner by encouraging occupational participation and balance.

Phases of development of the program

There were a number of different phases that the development team progressed through in establishing this program. While narrative in its presentation it outlines the collaborative and systematic approach that was taken to evolve from a spark of an idea to a functioning virtual program to support the community and support the student’s educational experience.

Initial phase

From the outset, it was decided that this program would provide free health and wellness services through a virtual platform, accessible to people from their own homes. While the idea stemmed from the COVID-19 pandemic, the faculty and students acknowledged that people experience numerous transitions throughout the lifespan, so this program would be designed to support people in maintaining optimal well-being during any difficult transition. These could include times when disease, injury or other life trauma impact a person but equally other transitions such as parenting, retirement and other significant changes in life that can result in noticeable impacts on a person’s health and wellbeing.

To assist with the development process, the faculty reached out to students who should have been starting their traditional fieldwork rotations to determine if any would be interested in participating in the development and implementation of the program as a Level II fieldwork experience. Ten students accepted the opportunity, and, following a series of Zoom video meetings, the early phases of program development began.

The team discussed initial ideas of what they envisioned for the wellness program and what they hoped to accomplish throughout the development process. Students researched extensively about the use of occupation in a wellness setting, its role during life transitions, as well as program development to better understand how to create a program from the ground up. The group collaborated early on to determine the mission and vision, and the name was intentionally established as the “Transition to Wellness Virtual Program”.

Theoretical basis

One of the first critical decisions was to select a theoretical lens through which the program would be developed. Because occupational adaptation is often challenged at times of transition, the group considered the Occupational Adaptation Model (11) and the Model of Human Occupation (MOHO) (12). The theoretical lens would serve as a guide to the occupation-focused evaluation and intervention processes to be utilized in the program. Ultimately, MOHO was chosen because it highlights the various individual and environmental components of a person and how they interact to influence occupational participation (12). Utilizing MOHO would allow the students to better understand a client’s motivation, roles, routines, and environments, providing insight into how to approach the intervention process to facilitate healthy transitions.

At this point, the students formed two working groups: the “theoretical group” and the “layperson’s group”. The theoretical group was tasked with delving deeper into the academic research related to MOHO and life transitions, and they formulated a guiding document that detailed the program from a theoretical perspective. The layperson’s group developed a document to explain the program in simple, appropriate language. The latter document formed the basis of information that would eventually be presented on program flyers and on the website as part of promotional material to launch the new program. Upon completion of these two documents, they were consolidated into a proposal that was presented to executive leadership within the School of Health Professions to facilitate the approval of the program.

Program evolution phase

After the theoretical and layperson’s groups completed the proposal development, they reconfigured into three different working groups (logistics, clinical, and marketing) for the specific program development process. The logistics team worked on determining how the programs’ everyday procedures would be completed. This included tasks such as determining what software to use for appointments and documentation, creating an initial phone screen for potential clients, and establishing general policies and procedures. To comply with the Health Insurance Portability and Accountability Act (HIPAA) standards and ensure client confidentiality, it was decided that the program would use a HIPAA-compliant Zoom^® platform to conduct sessions, and REDCap^® would be used for secure data collection and documentation. A Manual of Policies and Procedures (MOP) was created in order to document all relevant information for the continuation and sustainability of the program.

The clinical team was charged with establishing the evaluation and intervention process. They focused on MOHO assessments in order to devise an evaluation process suitable for the program’s needs, and they adapted the Role Checklist^©, the Occupational Circumstances Assessment Interview and Rating Scale^© (OCAIRS), and the Occupational Self Assessment^© (OSA) to be better-tailored to evaluate a person experiencing a life transition. MOHO assessments and interventions are distributed through the University of Illinois at Chicago and have all been psychometrically validated using classical test theory and RASCH approaches (13). For practical ease in application, these assessments were combined into a single document to serve as the initial evaluation for all clients.

The marketing team constructed the website, discussed marketing strategies, created interest surveys, made client satisfaction surveys, and established a program implementation plan. That plan encompassed the development and distribution of promotional material as well as a phased approach to rolling out the program, from an initial pilot phase to eventually expanding it to the general UAB community.

Program implementation phase

The working groups spent eight weeks in the development phase before moving onto implementation, which began with a pilot cohort of participants. Initially, first-year OT students were recruited to participate to provide the team with the opportunity to trial the format and delivery of the initial evaluation and intervention sessions. This allowed for feedback from people unfamiliar with the program so that any issues could be resolved before extending the program to the wider community.

After these initial interactions, the team expanded the participants to include friends and family of the implementation team. The students were paired with unfamiliar people so that they could experience a more authentic practitioner-client dynamic, and the inclusion of friends and family members presented a realistic picture of client progression through the program, from initial contact to discharge. Through this pilot group, the students began to gain experience with occupation-based interactions with clients and were able to explore what health and wellness interventions might look like in practice.

Case study

The following case example demonstrates the process of the Transition to Wellness Program and how it transformed the life of a participant.

Kasey*, a 24-year-old female graduate student, experienced an unexpected transition due to the COVID-19 pandemic. She went from attending classes on-campus to participating in online learning. She also picked up a part-time job as a child caregiver and began drinking coffee daily to make it through her shift. No longer being on-campus with a set daily schedule impacted Kasey in many ways.

The OT assessments identified several areas that were directly affected by Kasey’s transition. Kasey was highly motivated by goal setting, task completion, and accountability, but had difficulty finding time to get things done due to a lack of sleep and a consistent routine.

With support from the Transition Program, Kasey established four overarching goals that she wanted to achieve during the program including wanting to go to bed earlier, having a structured daily and nightly routine, reading more, and making exercise a priority.

Following goal planning, they implemented intervention strategies to begin working towards Kasey’s goals. Firstly, she was provided with a sleep log to complete each day that included wake-up time, naps, bedtime, quality of sleep, and a space to record what helped and what was difficult. Along with completing the sleep log, Kasey began reducing her coffee intake after 2 p.m., reading before bed, and limiting screen time between 9 p.m. and 8 a.m.

After a few weeks of working with Kasey, she learned to prioritize sleep hygiene through mindfulness activities and other techniques. She began going to sleep earlier and becoming more productive throughout the day. Once her sleep and daily routine improved, they turned the focus to her next area of concern: exercise. Together, they worked to incorporate occupation-based activities to promote exercise into her newly established daily routine.

By engaging in OT-based intervention strategies, Kasey has improved her sleep quality and quantity, has become more productive with her time, and has re-introduced exercise into her routine. Kasey remains motivated and continues to limit screen-time and to read before bed. She is also exercising more consistently, three times a week, and is working towards her long-term goal of making exercise a daily priority. When asked about her feelings on the program, Kasey commented, “This program has provided me with the encouragement and accountability to successfully transition and healthfully benefit from a routine that makes me feel content”.

Impact of the program

The Transition to Wellness Virtual Program was originally conceived to support people as the full impact of the pandemic on daily activities and occupations emerged. In addition, it was a needed solution to the curtailment of clinical rotations that was impacting student progression through their degree programs. Since being made available to the community the program has seen many tens of clients, offering much-needed wellness services while serving as a fieldwork opportunity for clinical students at a time when there is a shortage of fieldwork placements. It will continue to give future students experience in a non-traditional, virtual setting and to demonstrate the pivotal role of professions such as OT in the emerging practice area of health and wellness.

Conclusions

In conclusion, the COVID-19 pandemic, as well as other disasters and significant life events, today and into the future, will continue to illustrate how the impact on people’s role, routines and daily life can have a major impact on people’s health, resilience and wellbeing. Recognizing that this is, in part, due to the “occupational transition” they are experiencing can help people to move forward in their lives. The application of occupation-based, collaborative interventions delivered where needed, through a virtual platform, can facilitate people to develop meaning and structure in their daily living that facilitates community integration, improves mental health and promotes functional independence.

It is important that traditional healthcare professions establish themselves as essential providers of wellness services to show their unique contribution to the ever-changing healthcare landscape. While, in many instances, these professions operate within the medical model, the Transition to Wellness Virtual Program sought to break the mold and highlights the benefits the profession can have for all people, outside the traditional, and at times, limiting medical model.

Recognizing the role of professions like OT in emergency response and long term recovery of individuals, communities and populations post-disaster will be critical as professions shape their future using technology to support reimagination of their role to ensure that it is in sync with changes in societal, climatic, geographical and economic contexts, as well as realign their work to meet the challenges of increasing incidents of people displacement due to climate, persecution, violence, poverty and other social injustice issues.

Acknowledgments

Funding: None.

Footnote

* name has been changed to protect the privacy of the individual.

Provenance and Peer Review: This article was commissioned by the Guest Editors (Donna J. Slovensky and Donna M. Malvey) for the series “mHealth: Innovations on the Periphery” published in mHealth. The article has undergone external peer review.

Peer Review File: Available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-21-35/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-21-35/coif). The series “mHealth: Innovations on the Periphery” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Orentlicher ML, Schefkind S, Gibson RW. Editors. Transitions across the lifespan: an occupational therapy approach. AOTA Press, The American Occupational Therapy Association; 2015.
2. Bridges W. Managing transitions: Making the most of change. Reading, Mass: Addison Wesley; 1991.
3. Cucinotta D, Vanelli M. WHO Declares COVID-19 a Pandemic. Acta Biomed 2020;91:157-60. [PubMed]
4. Luck KE, Doucet S, Luke A. Occupational disruption during a pandemic: Exploring the experiences of individuals living with chronic disease. Journal of Occupational Science 2021; [Crossref]
5. Hinojosa J, Kramer P. Statement--fundamental concepts of occupational therapy: occupation, purposeful activity, and function. Am J Occup Ther 1997;51:864-6. [Crossref] [PubMed]
6. Zemke R, Clark F. Occupational science: An evolving discipline. Philadelphia: F.A. Davis; 1996.
7. Townsend E, Polatajko H. Enabling occupation II: Advancing occupational therapy vision for health, well-being and justice through occupation. CAOT Publications ACE; 2007.
8. Wilcock AA. An occupational perspective of health (2nd ed.). Slack; 2006.
9. Nizzero A, Cote P, Cramm H. Occupational disruption: A scoping review. J Occup Sci 2017;24:114-27. [Crossref]
10. Reitz SM, Scaffa MECommission on Practice, et al. Occupational Therapy in the Promotion of Health and Well-Being. Am J Occup Ther 2020; [Crossref] [PubMed]
11. Schkade JK, Schultz S. Occupational adaptation: toward a holistic approach for contemporary practice, Part 1. Am J Occup Ther 1992;46:829-37. [Crossref] [PubMed]
12. Kielhofner G, Burke JP. A model of human occupation, part 1. Conceptual framework and content. Am J Occup Ther 1980;34:572-81. [Crossref] [PubMed]
13. WebMOHO. 2021. Available online: https://www.moho.uic.edu/