Geriatrics Commons^™

Perioperative Outcomes And Mortality In Liver Transplant Patients 65 And Older, Nathaniel S. Pester, Trevor J. Wilke, V K. Shostrom, Cale A. Kassel

Graduate Medical Education Research Journal

Background: The number of patients over the age of 65 awaiting liver transplantation (LT) continues to grow and an increasing number of patients will undergo liver transplantation. While age is not an absolute contraindication to liver transplantation, understanding the risks to older patients remains essential to ensure good outcomes with the limited number of grafts available.

Methods: This retrospective study included patients undergoing LT at the University of Nebraska Medical Center. A total of 421 patients were enrolled and stratified to patients under 65 years old (351 patients) and patients over 65 (70 patients). Geriatric patients were defined as aged …

Epidemiology Of Older Patients Presenting To Irish Emergency Departments: A Subgroup Analysis Of The Egers Dataset, Sean Croughan, Arina Kruis Dr, Kelly Ann Catherine Janssens Dr, Pro Mukerjee Dr, Denys Shchetkovskyy Dr, Áine Mitchell Dr, Mehmet Akif Karamercan Dr, Zerrin Defne Dundar Dr, Anna Slagman Dr, Effie Polyzogopoulou Dr, Sandor Somodi Dr, Andrea Fabbri Dr, Lars Peter Bjornsen Dr, Wilma Beetge, Said Laribi, Rebecca Ann Sealy, Visnja Nesek Adam, Comfort Adedokun Dr, Lucy Gibbons, Pamela O’Brien, Jessica Lynch Dr, Laura Kenny, Conor Deasy Dr, John Ryan Dr, David Menzies Dr, John Cronin Dr, Vijay Narayanan Dr, Nurali Noorani Dr, Waslet Bakhshi Dr, Ahmed Al Rasheed Ahmed Dr, Rosa Mcnamara Dr

Journal of Geriatric Emergency Medicine

Introduction

Within Emergency Medicine, older adults represent a distinct population with unique needs and challenges. There is a scarcity of epidemiologic data on the requirements of Ireland’s older population for, and their utilisation of, emergency care networks. We sought to assess this deficit utilising data from the recently published European Geriatric Emergency Departments Registry Study (EGERS) dataset.

Methodology

A prospective, cohort study of older adult patients (≥65) presenting to Irish Emergency Departments over a 7-day period. The dataset was originally collected as part of the EGERS study. The Irish subpopulation was extracted, analysed in further detail, and compared to the …

Il-12 Encoding Ondv Synergizes With Car-T Cells In Orthotopic Models Of Non-Small Cell Lung Cancer, Amanda Rosewell Shaw, Daisuke Morita, Caroline E Porter, Eric Tu, Greyson W Biegert, Sonia Agrawal, Nicholas Durham, Malcolm K Brenner, Masataka Suzuki

Faculty, Staff and Students Publications

Systemic administration of oncolytic viruses (OVs) is a promising approach for targeting metastatic solid tumors, but their anti-tumor activity is limited by pre-existing neutralizing antibodies against common human viruses. Therefore, investigators have developed OVs derived from non-human host viruses. Successful implementation of this strategy requires that the viral vector selectively infects and replicates within human cancer cells. Newcastle disease virus (NDV) is an avian paramyxovirus that, as NDV-based OVs (oNDVs), has demonstrated safety and activity against multiple human tumors in clinical trials. Their use as a single agent, however, is insufficient to cure tumors. Similarly, chimeric antigen receptor-modified T cells …

The Doing, Being, Becoming, And Belonging Of Intergenerational Collective Occupations, Gladys Garcia, Jazminne Orozco-Arteaga

Fall 2024 OTD Capstone Symposium

Background: Older adults have been globally recognized as a vulnerable population. Literature has indicated that intergenerational engagement can decrease social isolation for older adults, but there is a gap in understanding intergenerational co-occupational engagement and how these engagements can improve quality of life and fulfillment of self-identity. The purpose of this qualitative research study was to generate knowledge of how relationships and occupations performed with individuals from a younger generation impacted sense of well-being. Through the lens of Doing, Being, Becoming and Belonging (Wilcock, 2006), the study sought to increase understanding of this lived experience to promote intergenerational practice within …

Enhancing Dignity Amongst Persons With Dementia Through Occupational Engagement, Habeeba Ahmed, Amy Lyons-Brown Ms, Otd, Otr/L

Fall 2024 OTD Capstone Symposium

Dementia is a cognitive impairment that impacts an individual's memory, judgement, safety awareness, and emotions which can interfere with their activities of daily living. As the condition progresses, the person living with dementia (PLWD) may require a care partner to help them complete their daily tasks. Having a care partner and being a care partner can be challenging for both, the PLWD and their care partner, as there begins to be a shift in their independence. The PLWD must rely on their care partner to help them throughout their day, leading to a decrease in independence and occupational engagement. When …

After-Hours, Severity, And Distance Are Associated With Non-Vha Emergency Department Use For Older Veterans: Insights From A Regional Health Information Exchange, Elina Kurkurina, Kimberly M. Judon, Ula Hwang, Kenneth S. Boockvar, Juan Wisnivesky, Matthew R. Augustine

Journal of Geriatric Emergency Medicine

Background: Older adults treated in emergency departments (EDs) are at higher risk for adverse outcomes. Using multiple facilities can worsen this issue through service duplication and poor care transitions. Veterans with dual insurance coverage can access both Veterans Health Administration (VHA) and non-VHA EDs. This study aimed to identify factors associated with non-VHA ED use among veterans.

Methods: We conducted a retrospective observational study of patients aged ≥ 65 who had primary care at the James J Peters VA Medical Center and at least one VHA or non-VHA ED visit between October 2017 and February 2020. Data were collected from …

Reducing Healthcare-Acquired Pneumonia In A Geriatric Long-Term Care Facility, Jacob R. Magsalin

Master's Projects and Capstones

Problem: Healthcare-acquired pneumonia (HAP) is a nosocomial infection that poses a serious threat in geriatric long-term care facilities due to its high morbidity and mortality.

Context: This evidence-based quality improvement project seeks to reduce the incidence of HAP in a geriatric long-term care facility in the San Francisco Bay Area by utilizing findings

from existing literature.

Interventions: Key interventions include improving and standardizing oral care techniques and promoting education on HAP prevention to allow patients and their families to be more proactive in preventing this complication.

Measures: Outcome measures include HAP diagnosis rates after implementation, any costs saved for the …

Implementing The Brief Confusion Assessment Method (Bcam) Delirium Screening Tool In An Emergency Department, Carolina Van Dalen

Master's Projects and Capstones

Problem: Persons with delirium have an elevated risk of falls. Thus, falls and delirium are inextricably linked. Both should be routinely screened for older adults.

Context: A 40-bed Emergency Department (ED) in the East San Francisco Bay area of Northern California and the first site among all acute care hospitals in the organization to implement the Brief Confusion Assessment Method (bCAM) delirium scoring tool within the Electronic Health Record (EHR).

Interventions: An EHR toolkit for delirium screening using bCAM was developed, tested, and implemented in the ED.

Measures: The outcome measure was the percentage of patients with a reported fall …

An Educational Video Guide To Aging In Place, Cecilia Ramos, Steven Gerardi Phd, Otd, Mss, Otr, Elizabeth Deluca-Berg Otd, Otr, Caps

Fall 2024 OTD Capstone Symposium

The growing population of older adults in the U.S. faces numerous challenges in maintaining independence while aging in place. Key findings from the needs assessment and literature review underscore the importance of accessible resources, health promotion, and health literacy in fostering autonomy and well-being among older adults. Occupational therapy addresses individual needs, educates on resource availability, and promotes interventions to enhance older adults' independence and safety. The purpose of this project was to create an educational video guide aimed at empowering older adults and their families with the knowledge and tools to overcome barriers to aging in place. This project …

A Multifactorial Fall Prevention Program, Virale Patel, Zeida Gutierrez

Fall 2024 OTD Capstone Symposium

Falls among older adults are a pressing public health concern, leading to significant physical, psychological, and economic consequences. This capstone project aimed to design and implement a multifactorial fall prevention program to address unmet occupational needs and enhance safety and occupational participation among long-term care residents at a skilled nursing facility. The six-week program included targeted weekly sessions focusing on behavior modification, footwear safety, adaptive equipment training, strength and balance exercises, toileting strategies, and environmental modifications. Pre- and post-program assessments utilized the Fall Efficacy Scale International (FES-I) and participant surveys to evaluate changes in confidence, fear of falling, and satisfaction …

Training Staff Members And Caregivers On Utilizing Allen Cognitive Levels To Aid Individuals Living With Alzheimer's And Dementia To Maintain Activities Of Daily Living, Kristy Boyd, Cassandra Nelson, Jennifer Summers

Fall 2024 OTD Capstone Symposium

This capstone project is about training staff members and caregivers on utilizing the Allen's cognitive levels to aid individuals living with Alzheimer's and dementia to maintain their activities of daily living by creating a program that consists of modules, physical demonstration, and a deliverable for staff members and caregivers as well as therapeutic activities and sensory regulation activities for the participants.

Delirium Screening Practices For Older Adults In Emergency Departments Across United States: A Scoping Review, Azmat Sidhu, Joy K. Luzingu, Sheneil Agyemang, Arushi M. Chalke, Grace M. Leito, Joseph A. Molina, Zhao Chen, Deborah Jean Mcclelland, Nimit Agarwal, Leah Steckler, Angela Wu

Journal of Geriatric Emergency Medicine

Delirium is commonly missed among older patients in the Emergency Department (ED). Identifying and managing patients with delirium in ED is critical to help improve health outcomes and prevent falls and readmission. There are several validated delirium screening tools but their utilization for assessing delirium in emergency department settings are still under investigation. The overall purpose of this review was to summarize information on current screening practices for delirium among older adults (65 or older) in EDs across United States and to identify current gaps in knowledge and evidence to help inform future research and practice. A comprehensive literature search …

Understanding The Perceptions Of Technology In Homes For Aging In Place, Jinelle Abugan, Amy Lyons-Brown Ms, Otd, Otr/L, Molly Wuebker Otd, Otr/L, Actcp

Fall 2024 OTD Capstone Symposium

The purpose of this study is to understand the thoughts and experiences of technology in homes and the use of technology-based home modifications to help individuals with participation and performance in daily activities. The education of perceptions of culture in homes will be supported by faculty, OTs, professional designers, about the need to explore culture in technology for home modifications aging in place.

Blood Biomarkers In Down Syndrome: Facilitating Alzheimer's Disease Detection And Monitoring, Melissa Petersen, Lisi Flores-Aguilar, Elizabeth Head, Laia Montoliu-Gaya, Andre Strydom, Sarah Pape, Juan Fortea, Nicholas Ashton, Chinedu Momoh, Sid O'Bryant

Brain and Mind Institute

Blood-based biomarkers continue to be explored for disease detection, monitoring of progression, and therapeutic outcomes as the diagnostic determination of Alzheimer's Disease in Down Syndrome (DS-AD) remains challenging in clinical settings. This perspective highlights the current status of this effort. Overall, amyloid (A), tau (T), and neurodegeneration (AT[N]) blood-based biomarkers have been shown to increase with disease pathology for individuals with DS. Phosphorylated tau biomarkers (p-tau217, p-tau181) have been consistently shown to track disease progression for DS-AD and are likely good candidates for use in clinical settings. Biomarkers of inflammation (glial fibrillary acidic protein) also show promise; however, additional work …

An Innovative Community‐Led Education And Recruitment Program To Increase Clinical Research Participation Among Black Americans, Bahar Niknejad, Ethlyn Mcqueen Gibson, Travonia Brown-Hughes, Katie Mcdonough, Ebony Andrews, Deborah Hudson, Hamid Okhravi

Glennan Center for Geriatrics and Gerontology Faculty Publications

Background: Previous studies attest to a lack of awareness about Alzheimer’s Disease (AD) and limited participation of Black Americans in AD clinical trials. The AHEAD Study is a multicenter trial focused on preventing AD by evaluating the effectiveness and safety of Lecanemab in individuals with preclinical AD. The study aims to recruit at least 15% from underrepresented populations, including Black Americans. To achieve this goal, our study site utilizes a community-based participatory research (CBPR) approach and developed a Community Education and Recruitment Program (CERP) designed to increase the participation of Black individuals in the AHEAD Study.

Method: In a collaborative …

Examining Anxiety And Coping Strategies With Persons With Parkinson's Disease (Pwpd) Who Routinely Exercise, Ashlynn Milburn, Angela Labrie Blackwell, Karen Aranha, Maggie Abbott

Fall 2024 OTD Capstone Symposium

Forty to 50% of the PwPD are reported to experience anxiety (Kwok et al., 2019). Anxiety is psychological distress characterized by excessive worry, and apprehension about future events (Khatri et al., 2020). Psychological distress with this population is secondary to care dependency, poor work and social function, increased physical and cognitive decline, increased dementia risk, and high mortality rate (Kwok et al., 2019).Exercise and meditation have been found to be useful coping strategies to manage one’s physical condition as well as psychosocial factors such as anxiety, with PD (Mantri et al., 2021).Although these coping strategies have the potential to reduce …

Efficacy And Feasibility Of Intradialytic Plantar Electrical Stimulation In Patients With Diabetes: A Randomized Double-Blind Controlled Trial, Myeounggon Lee, Abdullah Hamad, Mehrnaz Azarian, Jaewon Beom, Abderrahman Ouattas, Mohammad Dehghan Rouzi, Naima Rodriguez, Nhi Quach, Rania Ibrahim, Mincy Mathew, Talal Talal, Fadwa Al-Ali, Bijan Najafi

Center on Aging Staff Publications

Objective: This study investigates the efficacy and feasibility of electrical stimulation (E-Stim) on sensory fibers of the plantar region during hemodialysis sessions, aiming to improve mobility in patients with diabetes by providing a connection between E-Stim and enhanced mobility with minimal patient effort required.

Research design and methods: Participants aged ≥18 years with diabetes undergoing hemodialysis and able to walk at least 10 m with or without aid were recruited and divided into an intervention group receiving 1-h intradialytic E-Stim three times a week and a control group using an identical nonfunctional device for 12 weeks. Gait, physical activity, patient-reported …

Initiation Of Hearing Aids Use And Incident Dementia Among Mid-To-Late Life Adults: The Health And Retirement Study 2010-2018, Jingkai Wei, Kun Li, Youngran Kim, Rahul Ghosal, Donglan Zhang, Anwar T Merchant, Casey Crump

Faculty, Staff and Student Publications

BACKGROUND AND OBJECTIVES: Hearing aids may reduce the risk of dementia among individuals with hearing loss. However, no evidence is available from randomized controlled trials (RCTs) on the effectiveness of hearing aids use in reducing incident dementia. Using target trial emulation, we leveraged an existing longitudinal cohort study to estimate the association between hearing aids initiation and risk of dementia.

RESEARCH DESIGN AND METHODS: The Health and Retirement Study was used to emulate target trials among non-institutionalized participants aged ≥50 years with self-reported hearing loss, without dementia at baseline, and without use of hearing aids in the previous 2 years. …

The Southern Nevada Care Economy: Addressing Child Care And Elder Care Challenges, The Lincy Institute

Lincy Institute Events

This community forum examines the economic and societal impact of the “care economy” in Southern Nevada in collaboration with Tripp Umbach, a nationally recognized consulting firm that provides comprehensive services including research and strategic plans to further the operations and activities of healthcare services.

Central to the care economy is elder care and child care. Having access to elder care and child care services is essential to working age adults, many of whom need one or both types of services to continue participating in the workforce. The delivery of child care and elder care services have far-reaching implications for our …

Nevada’S Care Workforce: Obstacles And Opportunities For Policymakers, David Damore, Caitlin J. Saladino, William E. Brown Jr., Fatma Nasoz

Policy Briefs and Reports

The care economy includes “the paid and unpaid labor and services that support caregiving in all its forms.” This work includes caring for children, the elderly, and those who are ill or have disabilities. Care work is often undervalued, underpaid, and without a fair system of work benefits in place (e.g. contracts, paid leave, workers’ rights) that in many cases falls disproportionately on women and communities of color. In this policy brief, we examine the care economy in Nevada by focusing on three areas of care: (1) child care; (2) elder care; and (3) mental and behavioral health care. In …

Utilization Patterns In Frailty: Don’T Miss The Forest For The Trees, Kathryn E. Callahan

Journal of Geriatric Emergency Medicine

No abstract provided.

The Infected Diabetic Foot: Does Negative Pressure Wound Therapy With Irrigation Reduce Bioburden And Improve Wound Healing?, Mehmet A Suludere, Matthew Malone, Michael C Siah, Arthur Tarricone, Tyler L Coye, Bijan Najafi, Lawrence A Lavery

Center on Aging Staff Publications

The aim of this study was to compare the microbial loads of patients with diabetic foot infections treated with negative pressure wound therapy (NPWT) with and without irrigation with polyhexamethylene biguanide (NPWTi-P). This is a post hoc analysis of combined data of two randomized clinical trials. We evaluated people with diabetes treated with moderate and severe diabetic foot infections that required surgery. Tissue specimens were obtained after the initial surgery and following a second planned return to the operating room after 48-72 h of NPWT or NPWTi-P, prior to the second surgery. We used quantitative polymerase chain reaction (qPCR) to …

Prevalence Of Serious Diagnoses And Disposition Among Older Adults Presenting With A Chief Complaint Of Constipation, A Retrospective Repeated Cross-Sectional Study, Ari B. Friedman, Michael N. Adjei-Poku, Rachel Gonzales, Rachel Kelz, Rachel R. Wu, Anne R. Cappola

Journal of Geriatric Emergency Medicine

A chief complaint of “constipation” in the emergency department (ED) is generally considered low-risk, and potentially suitable for lower acuity care. However, it may also indicate abdominal pain perceived as lower severity by triage staff, despite being relatively high-risk. We hypothesized that ED visits for constipation in older adults would more frequently result in the diagnosis of serious, treatable conditions compared to younger adults. We analyzed data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) over an 8-year period (2013-2020). Older adults with constipation were more likely to be non-Hispanic White. Among adults with constipation, 25.6% (95% CI: 22.8-28.4) …

Integrating Geriatric House Call Practice Into Paramedic Education: A Novel Educational Approach On Attitudes And Acceptance, Phillip D. Magidson, Mariah L. Robertson, Robby May, Mattan Schuchman, Eric Garfinkel, Matthew J. Levy

Journal of Geriatric Emergency Medicine

Objective: This study aimed to assess the feasibility and acceptance of integrating geriatric house call practice clinical exposure into paramedic education and to explore the impact on attitudes towards older adults among paramedic students.

Methods: Paramedic students from a fire department training program participated in a geriatric house call practice in collaboration with an academic health system. Pre- and post-program surveys were conducted to evaluate changes in attitudes towards older adults using the Ageing Semantic Differential (ASD) scale. Patient feedback on paramedic involvement was collected through post-visit surveys.

Results: Six paramedic students completed 25 house call visits over eight weeks. …

Using Patient-Reported Experiences To Inform The Use Of Foam Dressings For Hard-To-Heal Wounds: Perspectives From A Wound Care Expert Panel, Kevin Woo, Nick Santamaria, Dimitri Beeckman, Paulo Alves, Breda Cullen, Amit Gefen, José Luis Lázaro-Martínez, Hadar Lev-Tov, Bijan Najafi, Andrew Sharpe, Terry Swanson

Center on Aging Staff Publications

Caring for patients with hard-to-heal (chronic) wounds requires a multifaceted approach that addresses their diverse needs, which can contribute to the complexity of care. Wound care providers must have a comprehensive understanding of the patient's comorbid conditions and psychosocial issues to provide personalised and effective treatment. Key quality indicators for effective wound care involves not only selecting appropriate local wound care products, such as foam dressings, but also addressing individual patient experiences of wound-related pain, odour, itch, excessive wound drainage, and self-care needs. The purpose of this review is to inculcate the wound care practice community, research scientists and healthcare …

An Expansion Of The Phenotype In Individuals With Syncrip-Related Neurodevelopmental Disorder, Tooba Shafiq, Joanna Feng, Lindsay Phillips, Kara Murias, Marcia Ferguson, Kristin Baranano, Alaina Acchione, Patricia Kipkemoi, Collins Kipkoech, Amina Abubakar

Institute for Human Development, East Africa

Disruption of genes within the HNRNP gene family has been observed in neurodevelopmental and neurodegenerative diseases. The HNRNP-Related Neurodevelopmental Disorders (HNRNP-RNDDs), while each unique, have been recently described with similar clinical and molecular features across variation in several genes. However, the phenotypic information on these patients is still lacking. In this case series we aim to describe the phenotypes that are associated with SYNCRIP-Related Neurodevelopmental Disorder (SYNCRIP-RNDD). We describe in depth ten novel individuals and one previously published individual with mostly de novo and predicted damaging variants in SYNCRIP, consistent with a diagnosis of SYNCRIP-RNDD. We also describe previously published …

Dementia Risk Reduction In The African Context: Multi-National Implementation Of Multimodal Strategies To Promote Healthy Brain Aging In Africa (The Africa-Fingers Project), Chinedu Momoh, Rachel Maina, Lukoye Atwoli, Karen Blackmon, Edna Bosire, Gloria Chemutai, Linda Khakali, Sylvia Mbugua, Zul Merali, Olivera Nesic Taylor,, Anthony Ngugi, Cyprian Mostert, Eunice Muthoni, Roselyter Riang’A, Mansoor Saleh, Shahin Sayed, Jasmit Shah

Brain and Mind Institute

Dementia prevention in Africa is critically underexplored, despite the continent's high prevalence of modifiable risk factors. With a predominantly young and middle-aged population, Africa presents a prime opportunity to implement evidence-based strategies that could significantly reduce future dementia cases and mitigate its economic impact. The multinational Africa-FINGERS program offers an innovative solution, pioneering culturally sensitive, multidomain interventions tailored to the unique challenges of the region. Leveraging insights from landmark global studies such as Worldwide-FINGERS and Alzheimer's Disease Neuroimaging Initiative, the program employs a multideterminant precision prevention framework, grounded in community based systems dynamics. Africa-FINGERS further integrates cutting-edge state-of-the-art multimodal biomarker …

Quantitative Biomechanical Analysis In Validating A Video-Based Model To Remotely Assess Physical Frailty: A Potential Solution To Telehealth And Globalized Remote-Patient Monitoring, Mohammad Dehghan Rouzi, Myeounggon Lee, Jaewon Beom, Sanam Bidadi, Abderrahman Ouattas, Gozde Cay, Anmol Momin, Michele K York, Mark E Kunik, Bijan Najafi

Center on Aging Staff Publications

Assessing physical frailty (PF) is vital for early risk detection, tailored interventions, preventive care, and efficient healthcare planning. However, traditional PF assessments are often impractical, requiring clinic visits and significant resources. We introduce a video-based frailty meter (vFM) that utilizes machine learning (ML) to assess PF indicators from a 20 s exercise, facilitating remote and efficient healthcare planning. This study validates the vFM against a sensor-based frailty meter (sFM) through elbow flexion and extension exercises recorded via webcam and video conferencing app. We developed the vFM using Google's MediaPipe ML model to track elbow motion during a 20 s elbow …

Inpatient Falls: Epidemiology, Risk Assessment, And Prevention Measures. A Narrative Review, Taylor Locklear, Jeannie Kontos, Callaham A. Brock, Alexander B. Holland, Rachel Hemsath, Anna Deal, Shannon Leonard, Carsten Steinmetz, Saptarshi Biswas

HCA Healthcare Journal of Medicine

Patient falls are a common inpatient dilemma and comprise the largest category of preventable adverse events in hospitalized patients. These events place a clinical burden on the patient, such as increased morbidity and reduced quality of life, in addition to an economic burden on the hospital system. Fall prevention strategies have the opportunity to decrease inpatient health care costs and length of stay. Several risk factors have been identified that contribute to inpatient falls and several strategies have been identified to minimize this risk. These risk factors are typically characterized as intrinsic and extrinsic factors. Intrinsic factors include characteristics such …

A Geriatric Interprofessional Education Workshop: A Mixed Method Study, Patricia Watford, Meghan Hall, Colleen Hergott, Wanda Jirau-Rosaly, Shilpa Brown, Elena Wood, Nicole Rockich-Winston

Journal of Applied Disciplines

Interprofessional healthcare teams are essential for meeting the needs of our older population. To prepare for interprofessional collaboration, educational programs should offer opportunities for interprofessional education. We created a four-hour geriatric interprofessional workshop addressing cognition, macular degeneration, dysphagia, home safety, fall risk, and pharmacotherapy to examine student perceptions of working in interprofessional teams and their attitudes toward geriatric patients. Participants included 189 second-year medical (MD) students, 41 first-year occupational therapy (OT) students, and 36 second-year physical therapy (PT) students. We utilized a sequential explanatory mixed-method approach. Data analysis comprised descriptive statistics, paired t-tests for the pre/post surveys, and inductive content …