Peters HiD Manuscript

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Running Head: THE EVALUATION OF MEMORY LOGS
The Evaluation of Memory Logs on a Brain Injury Unit
Emily S. Peters
Elizabethtown College

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The Brain Injury Association of America (BIAA) (2013) estimates that there are 5.3
million Americans who are currently living with a long-term disability as a result of a traumatic
brain injury (TBI). One of the greatest challenges experienced by this population following a
brain injury is memory impairment (Armstrong, McPherson, & Nayar, 2012; Pendleton, 2013).
According to the literature, one of the most effective interventions to treat memory impairment is
the use of an external memory aid (McKerracher, Powell, & Oyebode, 2005). These tools are
utilized in many inpatient rehabilitation settings. One such facility, WellSpan Surgery and
Rehabilitation Hospital (WSRH), expressed the need for a program evaluation to examine the
effectiveness of the use of memory logs by staff on the Brain Injury Unit. This program
evaluation was conducted collaboratively by an external evaluator, an occupational therapy
student from Elizabethtown College, and two on-site occupational therapists at WSRH. The
results lead to a plan for the implementation of recommended changes which will improve the
overall effectiveness of memory log use by staff at WSRH in the future.
Literature Review
This review will begin by providing a brief overview of brain injury etiology and
prevalence in the United States. The subsequent sections will discuss memory function relative
to brain injury, and examine the respective advantages and disadvantages of remedial and
compensatory approaches to treatment of memory impairment. External memory aids will be
introduced as one of the most effective interventions for memory impairments. Three different
implementation protocols for memory notebooks will be discussed in chronological order of their
publication date. WSRH will be introduced as a facility that is currently using memory
notebooks to address the memory impairments of clients receiving treatment in a Brain Injury
Program. This section will conclude with a description of the components of a program

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evaluation that was conducted at WSRH to examine the current effectiveness of memory logs by
staff.
Overview of Brain Injury in the United States
According to the National Institute of Health (NIH) (2013), 2.6 million people will
sustain a brain injury each year in America. Brain injuries can be classified as either traumatic or
acquired. A traumatic brain injury (TBI) may occur when there is a direct blow to the head. The
most common causes of a TBI are falls, motor vehicle accidents, sports-related injuries, and
violent assaults. The most at risk groups for a TBI are children between the ages of 0-4 years,
adolescents between the ages of 15-19 years, and older adults over the age of 65 years. In all age
groups, males are more likely than females to sustain a TBI (National Institute of Health, 2013).
In contrast, acquired brain injuries are not induced by trauma. They can occur at any stage in the
lifespan as a result of a cerebrovascular accident (CVA), brain tumor, brain infection, or other
anoxic/hypoxic event (Brain Injury Association of America, 2013).
Both traumatic and acquired brain injuries cause damage to neurons surrounding a given
lesion. Necrosis can result in deficits in motor, cognitive, perceptual, and speech functions.
Function following a brain injury is variable among individuals and depends on the location and
severity of the lesion. One of the most pronounced challenges experienced by this population is
memory impairment (Armstrong, McPherson, & Nayar, 2012; Morris & Reinson, 2010;
Pendleton, 2013; Sandler & Harris, 1992). As many as 80% of clients who sustain a brain injury
will experience a memory impairment as a result of the injury (Barker-Collo & Feigin, 2008).
Memory impairment can have a significant impact on an individual’s functional independence in
everyday, meaningful occupations.

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The Impact of Brain Injury on Memory Functions
Following a brain injury, each client is unique in terms of the resulting of a memory
impairment. Location and severity of the brain lesion determine how memory function is
impacted. Memory function can be divided into various subtypes, including prospective and
retrospective memory (Morris & Reinson, 2010). Prospective memory is one’s ability to
remember to do things in the future. For example, prospective memory is applied when one
remembers to engage in a nightly medication regime before going to bed. According to Fleming,
Shum, Strong and Lightbody (2005), prospective memory is the most commonly impaired type
of memory as a result of a TBI due to the vulnerability of the prefrontal lobe as the site of either
coup or contrecoup. Retrospective memory is the ability to remember past events or previously
learned information (Fleming et al., 2005), and is also often impacted following a brain injury.
An example of the use of retrospective memory is when an individual recalls what they ate for
breakfast that morning.
Addressing Memory Impairments in Rehabilitation
One’s daily habits, routines and roles can be disrupted as a result of compromised
memory function (Morris & Reinson, 2010). Memory deficits can significantly limit one’s
functional independence and can lead to frustration and embarrassment. Early in the acute stages
of a brain injury, a rehabilitation team should address memory impairment in treatment in order
to achieve the best possible outcomes for the client (Fleming et al., 2005).
Within rehabilitation, there are two primary approaches that can guide the treatment:
remediation or compensation (Fleming et al., 2005; Pendleton, 2013). A remedial approach to
the treatment of memory impairment focuses on restoring an individual to their prior level of
functioning by re-establishing neural networks that were lost as a result of the brain lesion. This

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is accomplished through the use of repetitive mnemonics or memory tasks. Remediation of
memory function has been shown to produce objective improvements on standardized test results
for clients with memory impairment. However, remediation has been unsuccessful in facilitating
the generalization of memory improvements to everyday, purposeful activities for clients
(Fleming et al., 2005).
According to McKerracher, Powell, and Oyebode (2005), a compensatory approach is a
more appropriate treatment for clients with memory impairments. In contrast to remediation, this
approach emphasizes modifying a client’s environment in a way that allows them to adapt to the
memory impairment (Mckerracher, Powell, & Oyebode, 2005). The aim of treatment is to
maximize the client’s abilities without directly addressing the underlying neurological cause of
the memory impairment (Fleming et al., 2005). Treatment may include adding or removing an
object from one’s environment, or modifying an aspect of one’s daily routine to facilitate optimal
memory function. Compensation for memory impairment has been shown to be successful in
promoting generalization of memory improvements to everyday, purposeful activities
(Pendleton, 2013). One of the most commonly-used compensatory interventions is providing the
client with an external memory aid. According to McKerracher, Powell, and Oyebode (2005),
external memory aids (EMAs) have been shown to be the most effective compensatory
intervention for clients with memory impairments.
External Memory Aids: A Means of Compensation
Memory aids come in many forms, including diaries, notebooks, calendars, journals or
activity logs. Memory aids can assist an individual with orienting to their surroundings,
remembering past events, organizing future schedules, and, in some cases, affirming their
progress since the onset of the impairment. According to Pendleton (2013), memory logs can

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assist in increasing a client’s self-confidence. Assuming a client has made progress in treatment,
reviewing what has been recorded in the memory aid can affirm accomplishments that have been
made in past therapy sessions. This affirmation of progress is a significant aspect of treatment for
individuals who have sustained a brain injury, considering that they often possess altered self-
concept as a result of the brain injury (Pendelton, 2013). Memory logs are widely utilized in the
rehabilitation setting and have the potential to be highly effective if used correctly (Barker-
Collor & Feigin, 2008).
According to Fleming et al. (2005), a precursor to successful memory aid use by the
client is self-awareness regarding their injury and abilities. This is essential for a client to
understand the purpose and correct use of a memory aid. Additionally, memory aids are most
effective when there is equal buy-in by all members of the interdisciplinary rehabilitation
treatment team (Armstrong, McPherson, & Nayar, 2012). All members of the team should
demonstrate a cohesive understanding of the purpose and value of memory aids. Several studies
have explored the use of memory aids, identified barriers and facilitators to successful memory
aid use, and developed recommendations for their successful implementation. The next section
focuses on methods to train clients and staff on the correct use of memory notebooks
(Armstrong, McPherson, & Nayar, 2012; Donaghy & Williams, 1998; Fleming et al., 2005;
Sohlberg & Mateer, 1989).
Acquisition, application, and adaptation.
Sohlberg and Mateer (1989) are known as the pioneers of the first widely-recognized
memory notebook training protocol. Their protocol consists of three phases: acquisition,
application and adaptation. First, in the acquisition phase, a question-and-answer format is used
to teach clients how to use the notebook. Next, in the application phase, role playing is used to

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teach clients how to record information in different sections of the notebook. Lastly, in the
adaptation phase, clients practice recording information in the notebooks in their natural
contexts. Upon its initial development, this protocol was the most widely-applied in brain injury
programs (Sohlberg & Mateer, 1989). However, the original protocol was subsequently criticized
by Donaghy and Williams (1998) as being too lengthy during the acquisition phase, confusing in
terms of the format of the memory notebook, and complex during the training process for those
who have underlying memory impairments.
Drawing on client’s strengths when using a memory notebook.
Donaghy and Williams (1998) suggested the application of a different memory notebook
training protocol as an alternative to that proposed by Sohlberg and Mateer (1989). Their new
protocol was titled the Alberta Hospital Ponoka (AHP) Memory Journal Programme.
According to this program, the three overarching goals of a memory notebook are to
record past and future events, help clients organize log notes, and train clients to use and
maintain the notebook independently. The formatting includes a section titled “Things to Do” for
each day, a section for a daily schedule under which events can be crossed out once they are
complete, and a section for daily notes. This program suggests that training a client how to use
the memory notebook should be done in five phases. Training sessions should be shorter in
duration compared to the original acquisition, application and adaptation protocol, but they
should occur more frequently. A distinguishing feature of this program is the emphasis placed on
drawing on clients’ strengths of immediate recall, procedural memory and old learning. Even
clients with the most severe memory impairment can benefit from drawing on these strengths
(Donaghy & Williams, 1998).

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Making it real for the client using a memory notebook.
A study published by Armstrong, McPherson and Nayar (2012) revealed yet another
approach to training clients and staff on the use memory notebooks in an inpatient rehabilitation
setting. The authors collected data through a literature review and semi-structured interviews of
eight occupational therapists who had experience providing treatment to clients with a TBI.
Based on their findings, they identified three overlapping processes that occur during successful
memory notebook training: (a) developing client insight, (b) getting client buy-in, and (c) getting
others on board. This program is tailored to occupational therapists as being the primary
initiators of the memory notebook training in the inpatient rehabilitation setting. The first step of
this program is to develop insight by educating the client on their brain injury. Decreased client
awareness of their memory impairment is one of the major barriers to successful use of a
memory notebook (Fleming et al., 2005). This phase emphasizes the emotional support of the
client through active listening (Armstrong, McPherson, & Nayar, 2012).
Next, getting client buy-in involves including the client in the decision-making process
when formatting the notebook. The client should feel in control and motivated to continue with
training. The last step, getting others on board, involves the occupational therapist recruiting
other members of the healthcare team, as well as caregivers, to assist with the training. Anyone
who is involved with the client should share the same perspective regarding the purpose, value
and expectation of the memory notebook (Armstrong, McPherson, & Nayar, 2012).
All three of these overlapping processes should ideally result in a process called making it
real. During this process, the therapist encourages the client to integrate their use of the memory
notebook into their meaningful, goal-oriented tasks. This encourages the client to maintain the
use of their notebook after discharge from an inpatient rehabilitation setting. Making it real for

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the client facilitates generalizability of the memory notebook that supports independence in
everyday life (Armstrong, McPherson, & Nayar, 2012).
Summary.
Training clients and staff on the purpose, value and expected use of memory notebooks is
essential to their effectiveness. As seen in the previous sections, three different protocols have
outlined recommendations that can be applied to assure quality service delivery when utilizing
memory notebooks in a rehabilitation setting. These implementation protocols can serve as
guides for facilities who are utilizing memory notebooks as part of a brain injury program.
WellSpan Surgery and Rehabilitation Hospital (WSRH) located in York, Pennsylvania, is one
such facility that is currently implementing the use of memory logs in a Brain Injury Program.
WellSpan Surgery and Rehabilitation Hospital
WellSpan Surgery and Rehabilitation Hospital functions as a part of the larger integrated
health care system referred to as WellSpan Health. WSRH is a fairly new facility that opened in
April 2012 and that offers orthopedic surgery, neurosurgery, and inpatient rehabilitation services.
Within the rehabilitation department, there is an inpatient Brain Injury Program, which is
described in the subsequent section.
The Brain Injury Program at WSRH is managed by an interdisciplinary team consisting
of occupational therapists, speech therapists, physical therapists, case managers, nurses, a
recreation therapist, and a rehabilitation psychologist. The development of the Brain Injury
Program was, and continues to be, based on the Medical Rehabilitation Standards Manual
(2012). These national standards are mandated by the Commission on Accreditation of
Rehabilitation Standards (CARF), and address criteria for the delivery of quality service from a
variety of specialties within rehabilitation. According to the Medical Rehabilitation Standards

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Manual (2012), “A Brain Injury Program is specialized, interdisciplinary, coordinated, and
outcomes focused” (p. 233). The result of a brain injury is highly variable among clients and can
lead to physical, cognitive, psychosocial and behavioral impairments. Ideally, a Brain Injury
Program should strive to address the needs of each client in each of these areas of function
(Brain Injury Program, 2012). One way that WSRH is working to uphold these standards is
through the use of Journey Binders and Memory Logs.
Every client is issued a Journey Binder by the nursing staff within the first few days of
their stay in the inpatient rehabilitation unit. This three-ring binder serves the purpose of
educating the client and caregiver about diagnostic and prognostic information, as well as billing
information. The sections are separated using dividers with tabs that indicate what is included in
each section. Binders are pre-assembled with documents regarding a specific diagnosis. For
example, a client admitted due to a TBI receives a different binder from a client who is admitted
due to a CVA. Documents can be added to the binder as needed throughout the course of
treatment. Journey Binders are intended to serve as an easily accessible resource and should
therefore be with the client at all times. This includes the client taking the Journey Binder to the
therapy gym when they are scheduled to receive treatment.
A client is issued memory log sheets to add to the front of the Journey Binder if the
treatment team feels that they would benefit from this type of intervention. Memory logs are
issued based on the professional judgment of the rehabilitation team. They are used to record the
client’s daily progress in therapy. The goal of the memory log is to optimize memory functions
by assisting the client with their recall of past events and organization of future events. Many
clients who are admitted to the Brain Injury Program are issued a memory log to compensate for
memory loss that has occurred as a result of the brain lesion.

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Program Evaluation
Program evaluation is an ongoing process which is necessary in order to best serve clients
who receive rehabilitation services. The objective of a program evaluation is to gather
information with the intention of answering questions that program managers have about a
program (McDavid & Hawthorn, 2006). In spring 2013, the administration of WSRH expressed
concern about the current use of memory logs by staff and they wished to conduct a program
evaluation. The primary objective of this program evaluation was to examine the effectiveness of
the use of memory logs by staff, and to identify barriers and facilitators relative to effective
memory log utilization. A secondary objective was to develop recommendations to improve the
overall effectiveness of memory log use by staff.
Type of program evaluation.
The intention of a formative type of evaluation is to examine program effectiveness in
order to provide feedback for program improvement. In a formative evaluation, it is assumed that
the program should remain in existence and its continuation is not questioned. This is in contrast
to a summative type of evaluation, which is concerned with providing information to make
decisions about a program’s overall worth. In this type of evaluation, a program’s continuation is
in question (McDavid & Hawthorn, 2006). Both types are necessary and essential components to
the program evaluation process. The program evaluation conducted at WSRH was formative
because the effectiveness of memory notebooks was being examined, and the existence of the
Brain Injury Program was not being questioned.

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General process of memory log program evaluation.
The structure of this program evaluation followed ten standard steps which guide many
program evaluations (McDavid & Hawthorn, 2006). The questions and their respective answers
relative to this program evaluation at WSRH were as follows:
 Who were the client(s) for the evaluation? The clients for this evaluation were the
administration at WSRH, staff providing inpatient rehabilitation services on the
Brain Injury Unit, and the clients consuming these services.
 What were the questions and issues driving the evaluation? Administrators at
WSRH were concerned about the current effectiveness of staff utilization of
memory logs. More specifically, they were concerned that memory logs were not
used consistently or properly according to the facility’s protocol.
 What resources were available to do the evaluation? An external evaluator (a
senior occupational therapy student at Elizabethtown College) was available to
commit the time in order to collect and analyze the data. On-site staff at WSRH
were also available to commit the time in order to offer insights regarding the
current use of memory logs. Two on-site occupational therapists were available to
serve as supervisors of the evaluator. No funding was necessary to complete this
evaluation.
 What has been done previously? No formal program evaluations to assess the
effective use of memory logs have been done thus far in the Brain Injury Program
at WSRH. As previously described, protocols for the use of memory logs with
brain-injured clients can be found in the literature (Armstrong, McPherson, &
Nayar, 2012; Donaghy & Williams, 1998; Fleming et al., 2005; Sohlberg &

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Mateer, 1989). This information was used to design data collection tools for the
program evaluation at WSRH.
 What was the program all about? As previously described, the Brain Injury
Program was WSRH was and continues to be based on the Medical Rehabilitation
Standards Manual (2012). The Brain Injury Program seeks to deliver services
which address each client’s individualized needs.
 What kind of environment did the program operate in and how did that affect the
comparisons available to an evaluator? The Brain Injury Program exists in an
inpatient rehabilitation setting, which is located within a larger hospital that offers
surgery services in addition to rehabilitation. The hospital is fairly new; It opened
in April 2012.
 Which research design alternatives were desirable and appropriate? The research
design that was deemed to be most desirable and appropriate in this context was a
qualitative design, as it promotes analysis of the subjective human experience.
Denzin and Lincoln (2000) explain, “Qualitative researchers stress the socially
constructed nature of reality, the intimate relationship between the researcher and
what is studied, and the situational constraints that shape inquiry” (p.8). This
program evaluation sought to understand the in-depth perspectives of staff who
are representative of a variety of disciplines at WSRH, and was conducted so that
the administrators of WSRH could understand the process of staff utilization of
memory logs.
 What information sources were available/appropriate, given the evaluation
issues, the program structure and the environment in which the program

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operated? The evaluator was unable to gain information from clients and family
members due to liability reasons, therefore access to information was limited.
However, the evaluator was able to collect information from staff at WSRH. The
qualitative design of the evaluation determined the methods of data collection,
which were semi-structured interviews and observations.
 Should the program evaluation be undertaken? It was decided that this program
evaluation should be undertaken. Administration at WSRH had expressed a need
for the evaluation, and the necessary resources were available.
Methods of Program Evaluation
This section will discuss the methods of this program evaluation. The first section will
specifically address the qualitative design of the evaluation. The subsequent section will discuss
how the participants were sampled. Next, the two types of data collection will be discussed, as
well as the data analysis procedures. Lastly, confidentiality and ethical considerations will be
addressed.
Program Evaluation Design
This program evaluation was conducted using qualitative methods. An inductive
approach to data collection and analysis was utilized, which meant that specific observations
were used to gain insight into broader themes (McDavid & Hawthorn, 2006). An assumption of a
qualitative design is that the world consists of multiple realities. In this program evaluation,
multiple staff were interviewed and observed in order to gain a broad understanding of varying
perspectives regarding memory log utilization. Data collection and analysis were descriptive and
interpretive, which are also characteristics of qualitative designs (Carter, 2011).

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Participants
The target sample size was eight to ten participants. The goal was to include at least two
staff from each of the following disciplines: occupational therapy (OT), physical therapy (PT),
speech therapy (SLP), and nursing. The plan was for eligible staff to be only those who treat
clients on the Brain Injury Unit. Staff who treat clients on the General Medicine or Surgery Units
were intended to be excluded from the sampling. The goal was to interview up to two staff from
each discipline, and to observe a total of four staff from different disciplines. Participants were
chosen via convenience sampling by the on-site supervisors.
Data Collection
Data collection occurred from November 2013 to April 2014. The two means of data
collection were semi-structured interviews and observations. Both were guided by instruments
developed collaboratively by the evaluator and the on-site supervisors. The evaluator suggested
content that should be included in the data collection instruments based upon characteristics
deemed to be important components of memory log implementation protocols as stated in the
literature (Armstrong, McPherson, & Nayar, 2012; Donaghy & Williams, 1998; Fleming et al.,
2005; Sohlberg & Mateer, 1989). Client and staff training regarding the use of memory logs, and
physical formatting of memory logs, are two examples of topics found in the literature that were
included in the data collection instruments. The on-site supervisors suggested content to be
included in the data collection instruments based on their perception of current memory log use
by staff.
Interviews were conducted using a guide (Appendix A), which was developed
collaboratively in advance by the evaluator and the on-site supervisors. Interviews addressed
staff perspectives’ regarding the purpose, expected use, and current effectiveness of memory log

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use at WSRH. Each participant engaged in a face-to-face interview which lasted approximately
30 minutes. The evaluator wrote brief notes during each interview, as they were not audiotaped.
Field notes were written immediately after each interview, which detailed the participant’s
responses to interview questions and nonverbal body language during the interview. The
interviews took place in a conference room located near the therapy gym at WSRH. The
evaluator and the interviewee sat at a medium-sized square table directly facing one another. The
evaluator and the interviewee were the only people present in the room during the interview.
Observations of staff during treatment sessions with clients were recorded using a
checklist (Appendix B), which was developed collaboratively in advance by the evaluator and
the on-site supervisors. The purpose of the observations was to gain greater insight regarding the
location of a memory logs throughout a treatment session, and the frequency of memory log
utilization. Each observation lasted approximately one hour. Field notes were written
immediately after each observation session, which further detailed the participants’ responses
and nonverbal body language. The opportunity to observe staff was determined by practicality.
Factors such as time constraints for the evaluator, the availability of the staff who could be
observed, and at what time the observation could occur.
Data Analysis
Thematic analysis using a constant comparative approach was used to identify emerging
themes across participants (McDavid & Hawthorn, 2006). The evaluator closely examined notes
from the interviews and observations, as well as the observation checklists, and identified
recurring themes across the data sources. To assist in the development of the themes, frequency
charts were used to organize the data. Data trustworthiness was enhanced using member
checking via email follow-up with participants, as well as triangulation across data sources.

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Confidentiality
Participant pseudonyms were used throughout this evaluation to protect staff
confidentiality. All participants were informed that the data recorded during observations and
interviews would be de-identified. Permission was granted by the administration of WSRH to
include the name of the facility in the results. Additionally, permission was granted by the two
on-site supervisors to include their names and credentials in the acknowledgement section of this
document, as well as on the associated poster.
Ethical Considerations
An application was submitted to The Institutional Review Board at Elizabethtown
College on September 25, 2013 to determine if the program evaluation met the criteria for
research involving human subject protections. The Board deemed that this project was not
research.
Results of This Program Evaluation
This section begins by describing the participants and the process of data collection.
Next, four themes are explained that were identified as a result of the data analysis.
Participants
The sample included eight participants who were representative of staff from a variety of
disciplines working in the inpatient rehabilitation setting at WSRH. Pseudonyms have been used
to protect staff confidentiality. The participants treated clients on the Brain Injury Unit, General
Medicine/Surgery, or both. As seen in Table 1, only two participants worked on the Brain Injury
Unit full-time. This was not in alignment with the original inclusion criteria, which stated that
only staff who worked on the Brain Injury Unit would be part of the sample. However, the

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number of staff who worked only on the Brain Injury Unit was limited. The evaluator and the on-
site supervisors agreed to broaden the sample in order to gain greater breadth of information.
Table 1
Participants
Participant Discipline Unit
David PT Brain Injury
Brad PT General Medicine/Surgery
Lori OT General Medicine/Surgery
Denise OT General Medicine/Surgery
Lisa SLP Brain Injury
Mackenzie SLP General Medicine/Surgery
Heather RT Brain Injury and General Medicine/Surgery
Amanda LPN Brain Injury and General Medicine/Surgery
Data Collection
Every participant engaged in one face-to-face interview. Participants varied in the
number of times they were observed due to practical reasons. It is important to note that two of
the participants, David and Lisa, worked full-time on the Brain Injury Unit and were observed on
more occasions compared to the other participants. This approach enhanced the applicability of
findings specifically to the Brain Injury Unit.

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Table 2
Data Collection Methods
Themes
As a result of data analysis, four themes were identified regarding the current utilization
of memory logs by staff at WSRH. The themes illustrate similarities and differences among staff
opinions regarding how and when memory logs should be used, as well as the ideal physical
format of memory logs.
Participants vary in their beliefs that memory logs should be issued to all clients versus
only those clients with a memory impairment. There was discrepancy among the staff in terms of
the underlying purpose of the memory logs. Some participants conveyed that memory logs are a
tool to assist only those clients who have a marked memory impairment. Denise stated, “They
[memory logs] are not always applicable to the patient.” The evaluator observed this belief
during an observation session with Denise. The client who was receiving treatment from Denise
Participant Discipline Number of Observations Number of Interviews
David PT Twice Once
Brad PT None Once
Lori OT Once Once
Denise OT None Once
Lisa SLP Three times Once
Mackenzie SLP None Once
Heather RT Twice Once
Amanda LPN None Once

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did not have a memory log. As described previously, Denise works on the General
Medicine/Surgery Unit full-time. She described during her interview that she treats primarily
clients who have an orthopedic diagnosis, and most of them do not have a memory impairment.
Therefore, she feels that memory logs are not necessary or appropriate for these clients.
On the contrary, other participants conveyed that memory logs can serve a broader
purpose. Mackenzie, a SLP, stated, “They [memory logs] can be used to log [all patient’s]
progress and increase their insight.” Lisa, also a speech therapist, conveyed the same belief
during her interview when she stated, “The memory log a serves a purpose greater than
reminding patients with a memory impairment of their to-do schedule. It can be a means of
organizing and reminding patients of their progress.” It is evident that staff have different beliefs
regarding the purpose and ultimate goal of memory logs.
The physical format of the memory log is not conducive to successful implementation.
The evaluator observed that memory log pages are placed in the very front of the client’s Journey
Binder. They are not indicated by a divider tab or label. The memory log sheets do not stand out
and grab the client’s attention. The sheets are organized so that each page provides blank rows
for every hour of the day that the client can use to record their daily therapy activities. There are
rows for 11 hours on each page. Some clients record activities completed outside of therapy
treatment sessions, but Brad revealed during his interview that most clients record only activities
that are completed during therapy treatment sessions. Brad proceeded to explain that this
typically results in unused space on the memory log sheet at the end of the day because each
client receives only three hours of therapy a day.
Many of the participants agreed that both the placement within the Journey Binder and
the layout of the memory log pages are not supportive to effective implementation of memory

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logs. Mackenzie stated, “Memory log sheets need to stand out more,” and Brad stated, “The
section for memory log sheets needs to be designated by a colorful divider tab.” These
statements illustrate that the staff perceived that the current physical format of the memory log
interferes with its successful implementation.
There is a lack of staff awareness regarding the expectations of memory logs and staff
roles in the implementation of memory logs. David, a PT, stated, “PTs don’t address cognition,”
in response to the evaluator questioning the location of the Journey Binder which was not present
in the therapy gym during an observation session. As stated previously, Journey Binders are
intended to be with clients at all times. When David’s client came to the gym without their
Journey Binder, David shrugged his shoulders and did not try and find the memory log. The
evaluator learned during the observation sessions that Journey Binders were not in the client’s
possession consistently. For example, sometimes the Journey Binders were left in the client’s
room when they went to the therapy gym for treatment, and other times they would take the
memory log to the therapy gym. This lead to memory logs being used at inconsistent times by
different staff members.
The evaluator also learned from participant interviews that there is inconsistency
regarding who issues the memory logs. They are sometimes issued by SLPs, and other times by
OTs, and this variability in the absence of policy results in memory logs not being consistently
issued. Heather stated, “The speech therapist initiates the memory log within the first week of the
patient’s stay,” and David stated, “Memory logs are issued by the speech therapist or the
occupational therapist.” Both of these statements, made during the participants’ interviews,
illustrate contrasting beliefs regarding staff roles and responsibilities in memory log

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implementation. During the observation sessions, the evaluator did not witness any memory logs
being issued.
Some of the participants believe that memory logs are currently being used ineffectively.
Six out of eight participants made statements that support this theme during their individual
interviews. Denise stated, “They [memory logs] are great in theory, but they aren’t working
here.” Denise proceeded to explain that she believes that memory logs are an effective
compensatory strategy for memory impairment, but lack of staff awareness regarding the
memory logs causes them to be ineffective at WSRH. Lori stated, “Memory logs are being used
inconsistently,” and David stated, “They are effective, but they are underutilized.” This theme
was also supported by data which was gathered during observations. For example, the location
where blank memory logs were stored was inconvenient. Participants conveyed during
interviews that the inconvenient location where memory log pages were stored made them less
likely to retrieve memory log pages when one was needed for a client.
Discussion
This section begins by interpreting the results which were described in the previous
section. These interpretations are followed by recommendations that may improve the overall
effectiveness of memory log utilization by staff at WSRH. The changes that WSRH wishes to
implement are addressed. Future program evaluation efforts, limitations, and implications for
practice conclude this section.
Interpretation of Results
Memory logs are currently being used ineffectively by staff at WSRH. Overall, there is a
lack of staff buy-in regarding memory logs, which is acting as a barrier to successful memory log
implementation. An additional barrier is the evident lack of policy to clearly define staff

23
expectations in memory log implementation. There is no formalized explanation of specific staff
roles in memory log implementation. This results in interdisciplinary discrepancy regarding who
is responsible for issuing memory logs, and which clients should be receiving memory logs.
These varying perspectives among staff are causing inconsistent and ineffective memory log
utilization. This is in alignment with the literature, which states that discrepancy of staff roles
within a program protocol can contribute to a lack of staff buy-in, and further decrease the
likelihood that a program will be effective (Armstrong, McPherson & Nayar, 2012).
Lisa and Mackenzie, both speech therapists, conveyed that they play an instrumental role
in issuing the memory logs, and they also conveyed that they believe that memory logs have a
broad purpose that can benefit all clients. This suggests that speech therapists are the staff with
the most buy-in and are therefore most likely to consistently utilize memory logs. David’s
statement, “PTs don’t address cognition,” implies that he does not believe that it is within his
scope of practice to address memory function. While it is most likely true that he does not have
specific treatment goals focusing on cognition, WSRH expects that all staff should be actively
aware of client’s cognitive status and support the goals of other disciplines. According to
protocol for the Brain Injury Program at WSRH, memory log utilization is not intended to be the
specific responsibility of any particular discipline, but rather to be universally utilized by all
disciplines. Armstrong, McPherson, and Nayar (2012) propose that “getting others [staff and
family] on board” is an essential component to successful memory log implementation.
Another barrier is the inconvenience of the location where blank memory log pages are
stored. Multiple staff reported that it is out of their way to go to the conference room, which is
not in close proximity to the therapy gym, in order to retrieve blank memory log pages when
necessary. In addition to this barrier, another contributing factor to the ineffectiveness of

24
memory logs is the placement and organization of memory log pages within the Journey Binder.
Memory log pages are not clearly labeled, nor do they capture the client’s attention with brightly
colored labels. These barriers suggest that developing potential recommendations for changing
the memory log protocol may improve the overall effectiveness of memory log utilization by
staff at WSRH.
Recommendations
Based on the results of the data analysis, the evaluator formulated a list of
recommendations that may improve the effectiveness of memory log use by staff at WSRH.
Additionally, if explicit policies and procedures would be made clear to all staff, this could be
used as a basis for further training and program evaluation at WSRH. The recommendations
made by the evaluator were:
 Move the blank memory log sheets to a more accessible location within the
therapy gym.
 Modify the physical format of the memory log pages.
 Initiate a staff in-service to: (a) establish a clear and detailed policy for memory
log utilization, (b) raise awareness about the unique roles and expectations of each
discipline in memory log utilization, (c) convey to staff that memory logs can be
beneficial for all clients.
 Change the label of the section in the Journey Binder from “memory log” to
“activity log.”
Moving the blank memory log pages to a more convenient location would increase the
likelihood that staff would retrieve them as necessary. This would further increase the likelihood
that memory logs would be utilized by staff.

25
As described in the Results of This Program Evaluation section, many staff reported that
the current placement and organization of memory log pages within the Journey Binder are not
conducive to effective implementation. Modifying the physical format of memory log pages in a
way that captures the attention of both clients and staff would increase the likelihood that they
would be used consistently. According to Sandler & Harris (1991), memory logs should be
brightly colored and include the patient’s name in large, easy-to-read letters. The evaluator
recommended that the memory log pages should either be printed on colored paper, rather than
white paper, or they should be indicated in the binder using a colorful divider tab.
The evaluator suggested that memory logs should be issued to all clients at WSRH, rather
than just to clients who have a marked memory impairment. The label “memory log” should shift
to “activity log” to illustrate that these tools can benefit all clients. According to Pendleton
(2013), memory logs can serve as a tool to assist in increasing a client’s self-confidence. When a
client reviews the activities that they have accomplished in a past therapy session, the review
may affirm the progress they’ve made as they compare this to their current level of performance.
Additionally, if every client received a memory log, the possibility of forgetting to issue a
memory log would be reduced or potentially eliminated because there would no longer be a
question about who should receive one. In order to accomplish this, the evaluator suggested that
memory log pages should be routinely included in all Journey Binders.
Lastly, the evaluator recommended that administrators at WSRH could initiate a staff in-
service to: (a) establish a clear and detailed policy for memory log utilization, (b) raise awareness
about the unique roles and expectations of each discipline in memory log utilization, (c) convey
to staff that memory logs can be beneficial for all clients. The purpose of this in-service would be
to increase staff buy-in by emphasizing the unique and specific role of each discipline.

26
Plans for Implementation
The evaluator conveyed the recommendations with the on-site supervisors at WSRH,
who proceeded to share these ideas with a Journey Binder work committee consisting of staff
from various disciplines. After discussing the list of recommendations, the committee agreed on
changes which they felt would be effective if implemented. The changes will be:
 “Memory Logs” will be referred to as “Activity logs.”
 Every client will receive a memory log.
 Activity Logs will be identified in the Journey Binders by a colorful tab that reads “My
Activity Log.”
 Therapy staff will be educated on their individual roles in the use of Activity Logs during
a weekly staff meeting.
Future Program Evaluation
The administrators of WSRH plan to educate the staff about their proper roles in the use
of Activity Logs during a weekly staff meeting. However, the following questions remain:
 How will they be educated?
 How will the unique roles of each discipline be implemented in the new Activity Log
protocol?
In order for the planned changes to be most effective, these questions should be thoughtfully
considered by the administrators at WSRH. Additionally, continued program evaluation is
necessary to measure the determined outcomes of the implemented changes. Further evaluation
should assess if the implemented changes resulted in more effective utilization of Activity Logs
by staff at WSRH. Questions to consider in further program evaluation include, but are not
limited to:

27
 Are Activity Logs used more consistently among staff from all disciplines in
comparison to the previous system of memory logs?
 Is the colorful divider tab that reads “My Activity Log” successful in capturing the
attention of both clients and staff?
Program Evaluation Limitations
The first limitation of this program evaluation was the small sample size. The participants
represented only 26% of the full-time, therapy staff, which limited the generalization of results to
all staff members. A second limitation was the method of sampling. The on-site supervisors
chose which staff would be involved, which limited the credibility of the results. The supervisors
may have held biases toward staff which influenced their interpretation of the results. A third
limitation was the lack of frequent contact between the evaluator and the participants. This
limited the opportunity to collect data via face-to-face interviews and observations. This was due
to practical reasons, such as scheduling conflicts and the distance between Elizabethtown
College and WSRH.
Implications for Practice
These results illustrate the importance of program evaluation in the clinical environment.
Without the program evaluation at WSRH, the concerns regarding memory log utilization by
staff may not have been recognized by the administration, and changes for improvement may not
have been developed and implemented. Program evaluation is an essential component of
ensuring quality delivery of rehabilitation services. The results also illustrate that greater,
facility-wide problems regarding productivity demands, space planning, and policy development,
can have an impact service delivery. At WSRH, inadequate policy development was having an
adverse impact on successful memory log utilization by staff. Additionally, inconvenient

28
placement of blank memory log sheets decreased the likelihood that memory logs would be
utilized. There is a need for administration in the clinical environment to assess these problems
in order to assure quality service delivery for clients.
Occupational therapists will often directly address cognition in the clinical environment.
They can apply these findings to the planning and implementing of external memory aids.
Occupational therapists should consider the therapeutic benefits of external memory aids not
only for those clients who have a memory impairment, but for all clients. They should also
understand how their responsibilities in memory log implementation at their particular setting
differ from the responsibilities of speech therapists and physical therapists. Occupational
therapists can advocate for a cohesive interdisciplinary approach to the implementation of
external memory aids by increasing staff buy-in regarding the therapeutic benefits of these
compensatory tools.
Conclusion
Multiple barriers relative to effective memory log use by staff at WSRH were identified,
including lack of staff awareness regarding roles in memory log implementation, and the
expected use of memory logs. The analysis of the results suggest that implementing changes to
the current protocol will improve the overall effectiveness of memory log use. In response to
recommendations for improvement that were developed by the evaluator, the administrators at
WSRH developed specific plans to implement several of the recommendations. Ongoing
program evaluation efforts will be necessary to ensure that the use of external memory aids at
WSRH will remain an effective component of their rehabilitation services.

29
Acknowledgements
I would like to recognize individuals who were fundamental to the success of this program
evaluation:
 Alicia Fry, M.H.A., OTR/L, WellSpan Surgery and Rehabilitation Hospital.
 Dr. Linda M. Leimbach, Sc.D., OTR/L, C/NDT, Lecturer, Elizabethtown College.
 Megan Dean, M.S., OTR/L, WellSpan Surgery and Rehabilitation Hospital.
 Staff participants at WSRH

30
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33
Appendix A
Interview Guide
1. As a (PT, OT, SLP, recreational therapist, or nurse) how do you work with patients who
have memory impairments?
2. (Depending on first question) What is your level of familiarity with memory notebooks?
a. In your opinion, what is the purpose of a memory notebook?
b. Are they an effective form of intervention for memory impairment? Why or why
not?
c. How do you know if a patient has a memory notebook?
d. If they do not have a memory notebook, how do you obtain one? Who issues
them?
e. Where is a patient’s memory notebook located?
3. Do you ever provide patient education regarding the memory log? If so, how do you go
about doing this?
a. Family/caregiver education?
b. Upon discharge, should the memory notebook be left in the rehabilitation hospital
or should the patient take it along with them? Do you encourage them to use it at
home?
4. How do you think the current system of memory books is working in this facility?
a. What do you like about the current method of using memory notebooks?
b. What barriers do you find when using the memory notebooks?
c. Should memory notebooks be the standard intervention used for all patients? Or
just those with a memory impairment?
d. What are ways that our approach could be more customized to meet the needs of
clients & families, without sacrificing efficiency & effectiveness?

34
Appendix B
Observation Checklist
This checklist will be used to record information regarding the utilization of memory logs by
staff during a treatment session. The “comments” section should be used to include additional
details about the checked boxes.
Date: _______________________________________
Time at beginning of observation: _______________________
Time at end of observation: ___________________________
Total amount of time spent observing staff: ___________________
Staff discipline observed:
Physical Therapy
Occupational Therapy
Speech Therapy
Nursing
Psychology
Recreation Therapy
Location of staff observation
Patient’s room
Rehabilitation gym
SLP office
Outside
Dining Room
Other
Purpose of staff interaction with patient:
Initial Evaluation
Intervention session
Care
Discharge
If intervention, specify what type:
ADLs:
Therapeutic exercises:
Patient education:
Functional mobility/gait/ambulation/stairs:

35
Transfers:
Homemaking tasks:
Cognitive tasks:
Other:
Section 1: Format of memory notebook
Yes No ----------------------------------------------------------------------------------------------
Outside of notebook is brightly colored
Patient’s name is written in large, easy-to-see letters on cover of notebook
Notebook includes daily schedule
Notebook includes orientation information (day of week, date of month,
season, etc.)
Notebook includes monthly calendar
Notebook includes a section to record notes
Notebook has a pen attached
There are extra log sheets in the back of the notebook
Comments:
Section 2: Location of memory notebook
Beginning of observation
Yes No Location
Located on bedside table
On wheelchair
In a drawer
In a file holder mounted to the wall or door
Not in the room
Other
Movedfor the first time
Yes No Location
On wheelchair
In a drawer

36
Not in the room
Other
Movedfor the second time
Yes No Location
On wheelchair
In a drawer
Not in the room
Other
Movedfor the third time
Yes No Location
On wheelchair
In a drawer
Not in the room
Other
Conclusion of observation
Yes No Location
On wheelchair
In a drawer
Not in the room
Other
Comments:
Section 3: Staff cuing and outcome
Type of cue & frequency Successful Unsuccessful
No cue given
Verbal cue 1x for memory notebook
Verbal cue > 3x for memory notebook
Verbal cue 1x for other memory aid

37
Verbal cue > 3x for other memory aid
Physical assistance 1x for memory notebook
Physical assistance for other memory aid
Comments:
Section 5: Education
Yes No ----------------------------------------------------------------------------------------------
Staff introduced memory notebook to the patient for the first time
Staff introduced memory notebook to the family for the first time
Staff verbally expressed the purpose of the memory notebook to the patient
[not for the first time]
Staff verbally expressed the purpose of the memory notebook to the family
[not for the first time]
[If being discharged] staff did not tell patient to take memory notebook along
with them
[If being discharged] staff did tell patient to take memory notebook along
with them
Comments:

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