Journal of Occupational Therapy Education, Vol. 5 [2021], Iss. 4, Art. 4 6 Lawrence et al.: Occupational Therapy Student Wellness: Focus Group Findings Procedures After Institutional Review Board approval was obtained, study coordinators used the institution's email distribution list to invite potential participants to the research study. Two focus groups were offered to accommodate for students' varying schedules. Both focus groups were held in the same location and lasted approximately one hour. All were given a written consent notice prior to the start of the session and then completed the demographic survey. Study coordinators then led the focus group (see Table 1). An audio-recording device was used to record each session, and the recordings were later transcribed verbatim. In total, there were 25 pages of transcription. After the study coordinators transcribed the audio recordings and ensured accuracy, the audio- recordings were deleted. Data Analysis Data from the focus groups were analyzed using transcript-based analysis (Onwuegbuzie et al., 2009). Study coordinators familiarized themselves with both focus group transcripts by reading the documents over multiple times while writing down initial thoughts and comments. Field notes taken by the principal investigator during the two sessions were also reviewed and both study coordinators read over the transcripts with these notes present. Once both study coordinators felt familiar with the transcripts, the transcriptions were independently coded by both study coordinators using constant comparison analysis. This was completed due to the fact that there were two focus groups within this study and coordinators were able to assess for data saturation (Onwuegbuzie et al., 2009). Constant comparison analysis includes three stages: 1) open coding, 2) axial coding, and 3) selective coding (Onwuegbuzie et al., 2009). In short, the data was chunked into small units; each small unit was then coded into a category. The categories were then grouped into themes. Once this was completed, the two study coordinators came together to share and finalize their individual thematic findings. The finalized thematic findings are detailed below. Study Trustworthiness Several strategies were intentionally chosen to ensure the trustworthiness and rigor of this research study. To start, two study coordinators, in addition to the principal investigator, were present during both focus group sessions. This helped to eliminate moderator bias. In addition to this, the principal investigator was present during both focus group sessions to take field notes. These notes were used to supplement the two focus group transcripts. Furthermore, peer debriefing took place throughout the research study to further reduce bias. The two study coordinators and the principal investigator came together to compare qualitative findings and ultimately finalize themes. After these themes were finalized, member checking took place to check for accuracy and validate results. Finally, the principal investigator, who has significant experience with qualitive research and data analysis, led the research study. Qualitative Data from Focus Groups Results Three themes emerged from the data: 1) wellness is a holistic concept; 2) graduate school is a novel experience; and 3) a group educational program that meets regularly could be beneficial for enhancing wellness. Each theme had two corresponding subthemes and additional exemplars, as outlined in Table 2. Wellness is a Holistic Concept Participants described wellness as a holistic concept when prompted. They described that "holistic" refers to multiple dimensions of wellness, including physical, mental, social, occupational, spiritual, and intellectual. When asked how they define wellness, one participant stated, "well...trying to have an equal balance of all six things [dimensions of wellness]" (Participant 5, Focus Group 2). Additionally, participants offered their own definitions of wellness as it related to various dimensions, "it's a holistic concept that wellness is...both mental wellbeing and social wellbeing and physical" (Participant 4, Focus Group 1). Despite these varying definitions, it was agreed that balance was important in maintaining or achieving an ideal level of wellness. Therefore, two subthemes emerged: 1) balance is a key component of achieving wellness and 2) wellness is highly individualized. Balance is a Key Component of Achieving Wellness. Participants indicated that balance was central to achieving overall wellness, "So, I think ideal wellness would be that balance of everything" (Participant 1, Focus Group 1). They discussed the difficulty of defining, finding, and maintaining this balance in both sessions. Overall, it was agreed that regardless of an individual's workload, stress, or other obligations, balance was crucial in order to achieve and maintain-wellness, "everyone will have different ideas of how much of a balance they need" (Participant 2, Focus Group 2). Wellness is Highly Individualized. Wellness was unanimously described as a highly individualized concept as the various dimensions may carry more or less meaning, depending on an individual's beliefs, interests, and overall goals, "I think wellness really means something different to everyone..." (Participant 6, Focus Group 1). Therefore, the dimensions one individual may focus on may differ from those of a peer and there is no "one size fits all" approach to enhancing wellness. This individualized nature of wellness inherently ties into balance, as the strategies may differ among individuals, "...wellness is accordingly how much of a balance of a healthy lifestyle...of a physical balance...of a mental balance... you need (Participant 2, Focus Group 2). Graduate School is a Novel Experience The participants discussed graduate school as a novel experience. Many expressed challenges associated with this transition, difficulties managing the work-life balance, and the impact these challenges have had on their wellness. "Just adjusting to living further away from home, away from my fianc...living in a city versus a rural place, just lots of factors..." (Participant 2, Focus Group 1). Although balance was discussed in this context, more of the focus was on the stress associated with graduate school as well as https://encompass.eku.edu/jote/vol5/iss4/4 DOI: 10.26681/jote.2021.050404 Published by Encompass, 2021 7 Journal of Occupational Therapy Education, Vol. 5 [2021], Iss. 4, Art. 4 8 Lawrence et al.: Occupational Therapy Student Wellness: Focus Group Findings the support sought out to smooth over the transition into the role of graduate student, "sometimes it also helps like knowing that the other person is also going through the same thing..." (Participant 2, Focus Group 2). Thus, two subthemes emerged: 1) graduate school is stressful and 2) various forms of support are important. Graduate School is Stressful. It was clear participants recognized graduate school as stressful, largely due to it being novel. The importance of wellness and occupational balance were easily linked to stress, "...there has been an identified need [for wellness programming] because of the stress that is so prevalent in academia and higher education..." (Participant 4, Focus Group 1). In general, participants understood the stress they were experiencing was a part of the graduate school "experience" but still expressed feelings of being overwhelmed, I remember doing something enjoyable wasn't always even enjoyable because I would be thinking like it was taking time away from something that I had to get done and that I was going to be more stressed about it later" (Participant 2, Focus Group 1). Various Forms of Support are Important. There was a general understanding of the importance of social support in the role of the graduate student. Participants discussed the experiences with social support and how some weeks they did not feel as supported, "I think most the time, maybe like 80% of the time, I feel really well- supported in my wellbeing, and then there's some weeks, like this week, that just like really like just kill me on the inside..." (Participant 6, Focus Group 1). Participants mentioned that support from their loved ones and friends was especially important while transitioning into a new graduate student role. Additionally, it was mentioned that support from the occupational therapy program (e.g., faculty members and the institution) was equally as important. Many students agreed that this support was present within the program, ...I feel like the intent is there... I do think the opportunity for you to be in this program and have high levels of wellbeing is absolutely there..." (Participant 4, Focus Group 1). Participants gave examples of ways in which they felt supported by their occupational therapy program, which included the program providing students with breaks throughout the day, offering opportunities for social interaction, sharing information on local places of worship, being transparent with students regarding assignments, and offering low-stakes practical assessments. A Group Educational Program That Meets Regularly Could Be Beneficial for Enhancing Wellness When prompted about programming related to wellness, it was indicated that a group process would be important if a wellness program was to be offered to graduate students in the future, I definitely agree that I think it would be beneficial and just a great opportunity..." (Participant 4, Focus Group 1). Many participants expressed interest in meeting with other interested students on a regular basis. In terms of content, participants stated they did not want program topics to focus on school, Yeah, I don't want to be talking about school" (Participant 8, Focus Group 1). Another participant commented during the focus group, So, I would not want it to be schoolwork assignment related but everything wellness strategies...absolutely" (Participant 4, Focus Group 1). Overall, it was unanimously agreed upon that a group program could provide wonderful opportunities to enhance wellness not otherwise offered. From this theme, two subthemes emerged: 1) students could hold each other accountable and 2) meeting regularly (e.g., weekly, bi-weekly) would be a feasible commitment. Students Could Hold Each Other Accountable. The benefits of accountability were positively discussed among participants, I benefit from accountability so like having people to talk to about, oh, what I've been doing or what I haven't been doing I think would help me kind of keep track of the different dimensions [of wellness]" (Participant 2, Focus Group 2). The importance of the accountability in future group programming was emphasized, I voluntarily have chosen it [wellness programming] so now I have personal buy in and if I stay with the same group the whole time now I've created strong relationships..." (Participant 4, Focus Group 1). Overall, it was made clear that students would be inclined to join a group program for the sake of accountability, in addition to enhancing their own personal wellness. Meeting Regularly (e.g., Weekly, Bi-Weekly) Would Be a Feasible Commitment. There were varying opinions regarding the time commitment for a future wellness program. Many participants agreed that an hour per week would be feasible. On the other hand, there were some participants who felt one hour per week was too much of a commitment, ... I feel like I'd do an hour like every other week. I don't think I could do a weekly thing because then I would just feel like a class" (Participant 1, Focus Group 1). In general, participants agreed that the day and time of the meeting, regardless of how often it occurred (e.g., weekly or bi-weekly), would have to be strategically chosen, "I think it would just have to, you'd have to really think about what time and what day you're putting it on..." (Participant 3, Focus Group 1). https://encompass.eku.edu/jote/vol5/iss4/4 DOI: 10.26681/jote.2021.050404 Published by Encompass, 2021 9 Journal of Occupational Therapy Education, Vol. 5 [2021], Iss. 4, Art. 4 4 Lawrence et al.: Occupational Therapy Student Wellness: Focus Group Findings examined a graduate-level classroom as a community of practice and how student learning was influenced by various activities and associated learning. The results of this study demonstrated that learning took place after students participated in various activities and assignments, either collaborative or reflective in nature (Kapucu, 2018). Further, communities of practice can facilitate learning through meaning social engagement and interaction (Kapucu, 2018). The findings of this study support that communities of practice are a practical and a potentially effective method to provide students with the social support and resources necessary to enhance subjective well- being and academic performance (Wenger-Trayner & Wenger-Trayner, 2015). Overall, a more holistic, evidence-based, and student-centered approach to addressing wellness would be beneficial for students currently enrolled in graduate-level programs as they prepare to transition into professional practice. A wellness program geared toward improving aspects of occupational therapy students' wellness may enhance the well-being and quality-of-life of the students involved. For example, Gutman et al. (2020) found that occupational therapy and physical therapy students engaged in a multimodal mindfulness program for eight weeks demonstrated a significant increase in categories such as sleep quality, energy levels, self-compassion, and life-work balance, as compared to the control group. These results demonstrate how purposeful interventions intended to enhance student wellness may have significant implications. In addition, a successful wellness program could potentially influence other institutions and graduate-level programs to design and to implement their own wellness programs. Since there is limited evidence on student wellness programming specifically supporting occupational therapy students, research supporting the need for this intervention could lead to improved wellness outcomes for participants that may last into professional practice. The purpose of this research study was to evaluate current occupational therapy students' perceptions of wellness and wellness programming, specifically if delivered via a community of practice. We anticipated gathering sufficient information from this study to proceed with program development in the future. Research Design Method A qualitative study design was selected to gather first-hand feedback from occupational therapy graduate students (Parsons & Greenwood, 2014). Primary data was collected via focus groups, which are commonly used to collect important information from a specific population or audience and are typically comprised of no more than 12 participants. During focus groups, participants are guided through a group discussion on a pre-defined topic (Rennekamp & Nall, n.d.). In past studies with graduate students, focus groups have been used by faculty members to better grasp students' perceptions on programming (Linville et al., 2003). Thus, a qualitative focus group study was used to gather information regarding current occupational therapy students' perceptions of wellness and of potential wellness programming delivered via a community of practice. The focus group served to ensure that any future programming meets the needs of the student population in content, frequency, and duration. Participants Participants were recruited via email from a convenience sample of a large, research- based Midwestern occupational therapy program. Entry-level master's, doctorate, and post-professional students enrolled in the occupational therapy program were included in the participant pool of approximately 220 students. Twenty-two students responded to our recruitment emails to participate in the study. To cater to varying schedules, two focus groups were offered. Of the eighteen volunteers who enrolled, fourteen were present for the scheduled focus group(s). The participants were mainly Master of Science in Occupational Therapy (MSOT) students (n = 8; 57.14%), but students from both the occupational therapy doctorate (OTD) program (n = 5; 35.71%) and post-professional doctorate (PPD) program (n = 1; 7.14%) also participated. Participants were enrolled in each year level, including first year (n = 4; 28.57%), second year (n = 9; 64.28%), and third year (n = 1; 7.14%). All participants were female (n = 14, 100%). The mean age was 25.71 years old (SD = 2.63, range = 22-28). Race and ethnicity were self-reported on the demographic survey as White (n = 9; 64.28%), East Asian (n = 1; 7.14%), South Asian (n = 2; 14.28%), and Black or African-American (n = 1; 7.14%). One participant selected two descriptors, White and American Indian/Alaskan Native (n = 1; 7.14%). Instruments Data was gathered from participants via discussion within the focus group meetings, which were audio-recorded. The questions were developed based upon project goals, current literature on student wellness and programming, and feedback from other members of the research team. See Table 1 for list of focus group questions. Table 1 Questions Asked in Focus Group Sessions Focus Group Questions 1. How do you define wellness? What does wellness mean to you? 2. Why are you interested in wellness programming? 3. Do you feel like the school environment supports your wellness? What about the profession of occupational therapy? 4. What dimensions of wellness are you most interested in as it relates to your role as an occupational therapy student? What area of wellness would you like to improve? 5. Do you feel that your role as a student hinders your ability to achieve any dimensions of wellness? Why? 6. Would you be interested in an in-person community of practice or a virtual community of practice? 7. Do you think involvement in a community of practice would benefit your wellness as it pertains to being a student? Why? 8. What do you hope to learn/take away if you were to be involved in a community of practice? 9. What amount of time are you willing to dedicate to participate? (e.g., 1 hour/week for 6 weeks, 30 minutes a week for an entire semester, etc.). = https://encompass.eku.edu/jote/vol5/iss4/4 DOI: 10.26681/jote.2021.050404 Published by Encompass, 2021 5 Journal of Occupational Therapy Education, Vol. 5 [2021], Iss. 4, Art. 4 10 Lawrence et al.: Occupational Therapy Student Wellness: Focus Group Findings Table 2 Themes, Subthemes, and Exemplars Theme Wellness is a holistic Subtheme Wellness is highly individualized concept Graduate school is a novel experience Balance is a key component in achieving wellness. Graduate school is stressful Exemplars from focus groups "Yeah, I think kind of going off that [wellness means something different for everyone], for me, it is having the time like to do what I need to do..." (Participant 3, Focus Group 1) "It [wellness] is very personalized..." (Participant 2, Focus Group 2) "...trying to have like an equal balance of all six things [dimensions of wellness], which is probably impossible but like as close as you I can get is what I feel like I would consider wellness to be" (Participant 5, Focus Group 2) "I think as a student it's hard to maintain all those dimensions of wellness and like when I start to take care of one more per say maybe like another one lessens a bit so it's just hard to keep it all balanced..." (Participant 6, Focus Group 2) "Yeah, I'm just going to be personally honest I have struggled a lot with stress here and have had to make a lot of adjustments that I guess I didn't see as stressful as... initially" (Participant 2, Focus Group 1) "...it's hard because a lot of the things that stress me out are things that I know are also important for me to practice" (Participant 2, Focus Group 1). A group educational program that meets regularly could be beneficial for enhancing wellness Various forms of support are important Students could hold each other accountable Meeting regularly (e.g., weekly, bi-weekly) would be a feasible commitment "I think something that's motivating is just like talking to your classmates right, and you hear how stressed everyone is and maybe an assignment goes out and you're like it's really not too bad..." (Participant 8, Focus Group 1) "I feel personally like very well supported at [our institution and program]... like if we are needing that [faculty support] and we reach out I think it's going to be well received" (Participant 5, Focus Group 2) "I like the element of accountability because I am held accountable for other things but not my wellness so like I do think a group would be beneficial..." (Participant 7, Focus Group 1) "Sometimes it also helps like knowing that the other person is also going through the same thing and you are not alone in this..." (Participant 2, Focus Group 2) "I think an hour a week is manageable...I know schedules are different people but um I think an hour a week is manageable" (Participant 5, Focus Group 2) "I mean ideally I would like to be doing something every week always. I mean for perfect wellness" (Participant 3, Focus Group 1) https://encompass.eku.edu/jote/vol5/iss4/4 DOI: 10.26681/jote.2021.050404 Published by Encompass, 2021 11