Beyond Basic Military Awareness: Cultural Competence In With Military .
NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 4 of 6 10/26/2019 BEYOND BASIC MILITARY AWARENESS: CULTURAL COMPETENCE IN WORKING WITH MILITARY AFFILIATED POPULATIONS PRESENTED BY DUANE K. L. FRANCE, MA, MBA, LPC 1 SAMSON TEKLEMARIAM, MA, LPC, CPTM Director of Training and Professional Development NAADAC, the Association for Addiction Professionals www.naadac.org steklemariam@naadac.org 2 2 PRODUCED BY NAADAC, THE ASSOCIATION FOR ADDICTION PROFESSIONALS WWW.NAADAC.ORG/WEBINARS 3 Presented by Duane K.L. France, MA, MBA, LPC 1
NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 4 of 6 10/26/2019 WWW.NAADAC.ORG/WEBINARS 4 4 ‐SERIES 5 5 CE CERTIFICATE CE HOURS AVAILABLE: 1.5 CE REGISTRATION TO ATTEND: 25 CE CERTIFICATE: INCLUDED To obtain a CE Certificate for the time you spent on this training: 1. Watch and listen to this entire webinar. 2. Pass the online CE quiz, which is posted at: ss‐ webinar 3. Maintain records of your invoice/receipt of payment and any CE certificate received from this series. 4. Email CE@naadac.org if you experience any difficulty with this process. 6 6 Presented by Duane K.L. France, MA, MBA, LPC 2
NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 4 of 6 10/26/2019 Using GoToWebinar – (Live Participants Only) Control Panel Asking Questions Audio (phone preferred) Polling Questions 7 7 WEBINAR PRESENTER Duane K. L. France, MA, MBA, LPC www.veteranmentalhealth.com duane@veteranmentalhealth.com Family Care Center, LLC 8 8 WEBINAR LEARNING OBJECTIVES 1 2 3 Describe the cultural aspects of military service, and how cultural aspects impact the worldview of the military affiliated population Recognize and understand the explicit and implicit characteristics of military culture and how they impact service members, veterans, and their families Articulate how culture impacts transition into and out of the military lifestyle and how this impacts individuals in post‐ military life Disclaimer: Presence of Department of Defense photos in this presentation does not imply endorsement by the Department of Defense or any affiliated agency or branch 9 9 Presented by Duane K.L. France, MA, MBA, LPC 3
NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 4 of 6 10/26/2019 COMPREHENSIVE VETERAN MENTAL HEALTH (REVIEW) Needs Fulfillment Moral Injury Purpose and Meaning Relationships Emotion Dysregulation PTSD Addiction TBI www.veteranmentalhealth.com/naadac4 10 CORE CLINICAL COMPETENCIES FOR TREATING SERVICE MEMBERS, VETERANS, AND THEIR FAMILIES (REVIEW) Military Culture represents general information about the functioning and worldview of military service members and their families. Ethics represents counselors’ self-awareness and motivation to serve military-connected clients, as well as ethical considerations working with military populations. Systems Features represents general information about the nature and structure of the military lifecycle including, but not limited to, deployment, family, spouses and children, health and wellness, employment, and retirement. Assessment of Presenting Concerns represents common areas of clinical concerns that service members frequently present to mental health services to address. Identity Development represents the whole person concept of military life including one’s personal identity as a service member and connection to mission and core values of working in a high-risk occupation across the lifespan. Treatment represents general information about unique issues that may arise in the treatment of military-affiliated clients and approaches supported by research for military populations, including best practices of military care systems, as well as holistic, wellness-oriented services. Advocacy represents counselors’ ability to understand and influence individual, system, and public policy efforts to increase access to mental health resources for military-connected clients and promote the role of counseling professionals working with military populations. Next up: Polling Question 1 www.veteranmentalhealth.com/naadac4 11 POLLING QUESTION #1 Assimilation into military culture and lifestyle can have a lasting impact on service members and their families A. Strongly Agree B. Agree C. Neither Agree or Disagree D. Disagree E. Strongly Disagree 12 12 Presented by Duane K.L. France, MA, MBA, LPC 4
NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 4 of 6 10/26/2019 CULTURE DEFINED Anything that defines the characteristics of a culture — ways of dressing, language, conceptualization of the world — applies to the military The integrated pattern of human knowledge, belief, and behavior that depends upon the capacity for learning and transmitting knowledge to succeeding generations The characteristic features of everyday existence shared by people in a place or time. The set of shared attitudes, values, goals, and practices that characterizes an institution or organization. The U.S. Army Old Guard Fife & Drum Corps take part in a ceremony, Sept. 30, 2019. DoD Photo by Lisa Ferdinando www.veteranmentalhealth.com/naadac4 13 SPECTRUM OF CULTURAL COMPETENCE Cultural competence needs to be seen as a continuum from basic cultural awareness to cultural competence; effort must be made to move beyond knowledge towards cultural sensitivity and competence (Adams, 1995). Cultural Awareness Developing sensitivity and understanding of another ethnic group Cultural awareness must be supplemented with cultural knowledge Cultural Knowledge Familiarization with selected cultural characteristics, history, values, belief systems, and behaviors of the members of another ethnic group Cultural Sensitivity Cultural Competence Has the ability to be Can Function appropriately effectively and responsive to the appropriately in diverse attitudes, feelings, circumstances of groups cultural interaction and settings of people that share a common and distinct racial, national, religious, linguistic, or cultural heritage www.veteranmentalhealth.com/naadac4 14 CULTURE DIFFERENCES Recognizes the unique within group cultural differences of Service members including gender, race, ethnicity, age, education, sexual orientation, socio‐economic status, ability‐status, and religious/spiritual orientation (Department of Defense, 2017). Among enlisted recruits, 43 percent of men and 56 percent of women are Hispanic or a racial minority. Women represent 16 percent of the enlisted forces across branches and 18 percent of the officer corps Enlisted recruits across the military join the military from neighborhoods where the median income is between 40k and 84k a year Age distribution varies between branches: enlistees below the age of 20 made up 84% of USMC, 65% of USAF and USA, and 67% of USN Deployed female service members reflect, look to future of women in uniform [Image 2 of 3] (U.S. Army photo by Cpl. Mariah Best) www.veteranmentalhealth.com/naadac4 15 Presented by Duane K.L. France, MA, MBA, LPC 5
NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 4 of 6 10/26/2019 RESOURCES BY COMPONENT Understands the potential for variance in the resources and support systems available to different components of the military (Active Duty vs. Reserve Component) Active Duty service members serve in specific locations around the U.S. and overseas and have the military as their full time occupation All branches of the military have a Reserve component, as well as each state has a National Guard and Air National Guard component As of 2014, over 800,000 National Guard and Reserve service members deployed in support of the Global War on Terror Non‐activated guard and reserve service members, from non‐combat eras, not eligible for VA services (Polusny et al., 2016) www.veteranmentalhealth.com/naadac4 Next up: Polling Question 2 16 POLLING QUESTION #2 Explicit characteristics of the military lifestyle can create a separate experience for those who served from those who haven’t A. Strongly Agree B. Agree C. Neither Agree or Disagree D. Disagree E. Strongly Disagree 17 17 EXPLICIT CULTURAL DIFFERENCES Explicit characteristics of military culture are those observable characteristics that make military life unique. Manner of dress, branch and era of service, era of service, and rank structure are all examples of explicit characteristics of the SMVF population Able to recognize different branches of service and differences in the characteristics of each Differences between current and former service members, as well as former service members from different eras Knowledge about different military operations, current and former, as well as differences between combat theaters within conflicts (i.e., Iraq vs. Afghanistan, Pacific vs. European theaters of operation) www.veteranmentalhealth.com/naadac4 18 Presented by Duane K.L. France, MA, MBA, LPC 6
NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 4 of 6 10/26/2019 EXPLICIT CULTURAL DIFFERENCES Can identify the Active Duty service branches of the U.S. armed forces, and understands that each branch adheres to specialized structures, roles, ranks, and terms and is aware that differences in military culture exist between each branch of service U.S. Army: the main ground force of the U.S., largest and oldest of all of the branches U.S. Air Force: the air and space branch of the military, began as Army Air Corps U.S. Navy: the naval force of the U.S., delivers combat forces while maintaining security at sea U.S. Marine Corps: An amphibious and ground expeditionary force U.S. Coast Guard: a maritime component; law enforcement branch and military branch www.veteranmentalhealth.com/naadac4 19 EXPLICIT CULTURAL DIFFERENCES Is aware that differences in experiences may exist between Veterans who previously served and Service members/Veterans who currently serve, as well as Veterans who served in different eras (DeBruyne & Leland, 2015) The military changes significantly over a short period of time; serving in 1995 was different than in 2005, which was different in 2015, etc. Military is an inherently dangerous occupation, with possible trauma and stress occurring even in times of “peace” According to a 2015 Congressional Research Service Report, the total number of U.S. Active Duty Military deaths in 1980 was 2,392, as opposed to 1,485 in 2010. World War II Era 1939 ‐ 1945 Post WWII Era 1945‐1950 Korean War Era –1950 to 1954 Post‐Korean War Era 1954 ‐ 1961 Vietnam War Era ‐ 1961 to 1975 Cold War Era –1975 –1990 Persian Gulf Era –1990 to 1992 Post Persian Gulf Era ‐ 1992 – 2001 Post 9/11 – 2001‐Present www.veteranmentalhealth.com/naadac4 20 EXPLICIT CULTURAL DIFFERENCES Seeks education on the training methods and objectives of military operations, including potential differences among combat zones. Potential Combat Conflicts: A service member’s experience in Iraq in 2010 is completely different than another service member’s experience in the Persian Gulf War in 1991 Technology, resources, method of combat differ from era to era and theater to theater A single service member, especially career military members, likely served in multiple conflicts; WWII and Korea, Korea and Vietnam, Vietnam and Persian Gulf War, Gulf War, Balkans, and GWOT World War II Korean War Vietnam War Lebanon Grenada Desert Storm/ Desert Shield Bosnia Kosovo Operations in the former Yugoslavia area Global War on Terrorism Operation Enduring Freedom Operation Freedom's Sentinel Operation Iraqi Freedom Operation New Dawn Mid-Webinar Q&A www.veteranmentalhealth.com/naadac4 21 Presented by Duane K.L. France, MA, MBA, LPC 7
NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 4 of 6 10/26/2019 Q&A Next up: Polling Question 3 www.veteranmentalhealth.com/naadac4 22 POLLING QUESTION #3 Implicit characteristics of the military lifestyle, such as internalized values, are not as important as explicit characteristics A. Strongly Agree B. Agree C. Neither Agree or Disagree D. Disagree E. Strongly Disagree 23 23 IMPLICIT CULTURAL DIFFERENCES Implicit characteristics of military culture are the underlying values and unwritten norms of behavior that are associated with military service. Just as important as explicit characteristics, these tend to remain in the veteran population after a service member is no longer in the military. Assimilation into the military culture inculcates values, beliefs, and traditions that impact an individual’s world view Military is a mission‐focused, process and results oriented organization Service members internalize military values such as sacrifice, honor, humility, collective effort, and a desire to limit risk or harm to others DoD photo by Maria L. Taylor www.veteranmentalhealth.com/naadac4 24 Presented by Duane K.L. France, MA, MBA, LPC 8
NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 4 of 6 10/26/2019 IMPLICIT CULTURAL DIFFERENCES A mental health professional needs to acknowledge that values, beliefs, traditions, and functions of the military can influence the client’s worldview. A particular worldview is a distinct philosophy of life or experiences within social, cultural, environmental, and psychological domains (Weiss & Coll, 2011). Military servicemembers and their families have more of a global perspective than those who have never served, due to multiple duty assignments All branches have a commitment to the value of service and sacrifice Exposure to trauma or stressful situations outside the common experience of those who didn’t serve can negatively impact values (moral injury) www.veteranmentalhealth.com/naadac4 25 IMPLICIT CULTURAL DIFFERENCES Is aware of the mission‐first, process‐ and results‐oriented value system of the military. A unified effort towards a common goal (macro or micro) is a significant part of establishing a cohesive collective culture. This is even translated to military spouses and children who operate in “everything else comes first” conditions Service members and their families experience a unique set of stressors, such as isolation from family of origin, frequent moves, and unpredictable changes, undertaken for the needs of the military and mission Putting mission before self can lead to a loss of personal identity and identity focused on military role A personal stake in the accomplishment of goals can lead to accepting an inordinate amount of responsibility for perceived failures A recruit looks through a compass during land navigation training, June 11, 2019. Marine Corps Photo by Lance Cpl. Christopher McMurry www.veteranmentalhealth.com/naadac4 26 IMPLICIT CULTURAL DIFFERENCES Acknowledges sacrifice, honor, and humility as values for Service members. Recognizes the importance of collectivism within the military culture, including a desire to limit risk or harm to others. This can impact their ability and willingness to seek mental health support for perceived weaknesses and a desire to protect others (Meyer & Wynn, 2018) Assimilation into military culture, either brief, short or long term, can lead to an indelible culturalization that is most significant in a veteran’s life Seeking care for mental health concerns can be seen as mission compromising and an admission that they are unreliable Often, service members and veterans will be reticent to disclose details, not to avoid reliving the trauma, but to “protect” the therapist from feeling what the veteran is feeling Air Force Master Sgt. Tiffany Robinson kneels in front of a battlefield cross, May 26, 2014. . Navy photo by Petty Officer 1st Class Eric Dietrich Next up: Polling Question 4 www.veteranmentalhealth.com/naadac4 27 Presented by Duane K.L. France, MA, MBA, LPC 9
NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 4 of 6 10/26/2019 POLLING QUESTION #4 The reasons for transitioning into and out of the military lifestyle are many and varied, and require a flexible approach to individual clients A. Strongly Agree B. Agree C. Neither Agree or Disagree D. Disagree E. Strongly Disagree 28 28 CULTURAL IMPACTS ON TRANSITION Acculturation into the military lifestyle impacts service members and their spouses, as well as to children and other family members. Understanding the challenges related to cultural dissonance is important for providers. The in‐group / out‐group nature of military service forms a psychological divide between those who served and those who haven’t Not all cultural assimilation is the same for service members, so providers need to explore the individual client’s response to military culture Clinicians must understand the different reasons why individuals join or leave the military, and their feelings towards these decisions There is a need to acknowledge and address the differing worldviews of those who served and those who haven’t. A Recruiter speaks to two U.S. Marines at the Warrior and Family Transition Fair on Marine Corps Base Quantico, Va., June 18, 2015. DoD Photo. www.veteranmentalhealth.com/naadac4 29 CULTURAL IMPACTS ON TRANSITION Providers must explore the introjection of military culture in the client’s personal and professional functioning. Although the veteran no longer exhibits the explicit characteristics of the military, their implicit characteristics are maintained and sometimes strengthened, such as the value of collectivism in the military versus the value of individual achievement. Military culture emphasizes working as a team, while non‐military employment culture is often focused on individual achievement and skills Inability to adapt to a different point of view can cause resentment and the feeling that military skills are not valued in post‐military life The need to make a cultural shift is not as emphasized during transition programs as is the development of skills and processes (Trussa & Castro, 2019) Personnel Specialist 2nd Class Kendra Velasquez from Syracuse, N.Y., Speaks with representatives from Commander Navy Region Northwest during a job fair. (U.S. Navy/Christopher R. Jahnke) www.veteranmentalhealth.com/naadac4 30 Presented by Duane K.L. France, MA, MBA, LPC 10
NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 4 of 6 10/26/2019 CULTURAL IMPACTS ON TRANSITION Respects the individual motivations of service members to enlist or commission in the military, as well as their individual experiences during their time in service and decision to leave or retire from the military. Service members show diversity in their reasons for why they join and leave the military, which branch they join, and how these impact how they view their service. Reasons for joining the military can be identified by themes (Redmond et al., 2015): Institutional: desire to serve, patriotism, desire for adventure/challenge Future‐oriented: desire for a military career and money for college Occupational: desire to support family, best available option Pecuniary: repayment of college loans and bonuses Army Chief of Staff Gen. Ray Odierno administers the oath‐of‐enlistment to future soldiers during a ceremony celebrating the U.S. Army’s 237th birthday at Times Square in New York, June 14, 2012. www.veteranmentalhealth.com/naadac4 31 CULTURAL IMPACTS ON TRANSITION Is aware of the potential for differing worldviews between Service members and civilians. In 2011, nearly 75% of those who served and those who haven’t served in the military agreed that the American public does not understand the military experience, the characteristics of military personnel, and military culture A comparatively small number of Americans serve in the military; the current and former service members only account for 6% of the national population This gap in understanding can increase difficulties for service members and their families leaving military culture Addressing the civilian‐military divide is seen to have political ramifications as well as a national security concern (Smith, 2018) Next up: Quote and Q&A www.veteranmentalhealth.com/naadac4 32 “ONE VETERAN I SPOKE WITH HAD INTERVIEWED FOR SEVERAL JOBS IN THE SAME INDUSTRY WITHOUT SUCCESS. HE ATTRIBUTED THIS TO HUMAN RESOURCES PEOPLE BEING BIASED AGAINST VETERANS. WHEN I POINTED OUT HIS NEGATIVE ATTITUDE TOWARD CIVILIANS AND ASKED IF HE THOUGHT HE HAD HIDDEN IT FROM THE INTERVIEWERS, HE ACKNOWLEDGED THEY PROBABLY HAD PICKED UP ON IT. ‘WOULD YOU HIRE SOMEONE YOU FELT HAD A BAD ATTITUDE TOWARD YOU?’ I ASKED. HE SAID HE WOULD NOT, YET HE PERSISTED IN BLAMING CIVILIANS RATHER THAN HOLDING HIMSELF ACCOUNTABLE FOR HIS ATTITUDE.” ‐ NAVY CHAPLAIN LCDR KEVIN S. BEMEL 33 Presented by Duane K.L. France, MA, MBA, LPC 11
NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 4 of 6 10/26/2019 REFERENCES Adams, D. L. (1995). Health issues for women of color: A cultural diversity perspective. DeBruyne, N. F., & Leland, A. (2015). American war and military operations casualties: Lists and statistics. Congressional Research Service Washington United States. Meyer, E. G., & Wynn, G. H. (2018). The importance of US military cultural competence. In Military and Veteran Mental Health (pp. 15‐33). Springer, New York, NY. Polusny, M. A., Martyr, M. A., Erbes, C. R., Arbisi, P. A., Kramer, M., Gibson, E., & Oleson, H. (2016). Prevalence and risk factors for post‐traumatic stress disorder symptoms among National Guard/Reserve Component Service members deployed to Iraq and Afghanistan. Comprehensive Guide to Post‐Traumatic Stress Disorders, 455‐487. Prosek, E., Burgin, E., Atkins, K., Wehrman, J., Fenell, D., Carter, C., & Green, L. (2018). Competencies for Counseling Military Populations. Journal of Military and Government Counseling, 87‐99. Redmond, S. A., Wilcox, S. L., Campbell, S., Kim, A., Finney, K., Barr, K., & Hassan, A. M. (2015). A brief introduction to the military workplace culture. Work, 50(1), 9‐20. Smith, A. (2018). “My Understanding Has Literally Changed”: Addressing the Military‐Civilian Gap with an Academic‐Community Engagement Project. Journal of Veterans Studies, 3(1), 1‐17. Truusa, T. T., & Castro, C. A. (2019). Definition of a veteran: the military viewed as a culture. In Military Veteran Reintegration (pp. 5‐19). Academic Press. US Department of Defense. (2017). Population representation in the military services. Weiss, E., & Coll, J. E. (2011). The influence of military culture and veteran worldviews on mental health treatment: Practice implications for combat veteran help‐seeking and wellness. International Journal of Health, Wellness & Society, 1(2), 75‐86. 34 34 Q&A 35 THANK YOU! DUANE@VETERANMENTALHEALTH.COM WWW.VETERANMENTALHEALTH.COM 36 Presented by Duane K.L. France, MA, MBA, LPC 12
NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 4 of 6 10/26/2019 www.naadac.org/military-vet-online-training-series 37 37 CE CERTIFICATE To obtain a CE Certificate for the time you on this training: CE HOURS AVAILABLE: 1.5 CE REGISTRATION TO ATTEND: 25 CE CERTIFICATE: INCLUDED 1. Watch and listen to this entire webinar. 2. Pass the online CE quiz, which is posted at: ss‐ webinar 3. Maintain records of your invoice/receipt of payment and any CE certificate received from this series. 4. Email CE@naadac.org if you experience any difficulty with this process. 38 38 WEBINAR SERIES INDEPENDENT STUDY COURSES Over 145 CEs of free educational webinars are available. Education credits are FREE for NAADAC members. Earn CEs at home and at your own pace (includes study guide and online examination). MAGAZINE ARTICLES CONFERENCES In each issue of Advances in Addiction & Recovery, NAADAC's magazine, one article is eligible for CEs. NAADAC Annual Conference, September 28 – October 2, 2019 Orlando, Florida www.naadac.org/2019annualconference FACE-TO-FACE SEMINARS CERTIFICATE PROGRAMS NAADAC offers face-to-face seminars of varying lengths in the U.S. and abroad. Demonstrate advanced education in diverse topics with the NAADAC Certificate Programs: Recovery to Practice Conflict Resolution in Recovery National Certificate in Tobacco Treatment Practice www.naadac.org/education 39 39 Presented by Duane K.L. France, MA, MBA, LPC 13
NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 4 of 6 10/26/2019 Thank you for joining! NAADAC 44 Canal Center Plaza, Suite 301 Alexandria, VA 22314 phone: 703.741.7686 / 800.548.0497 fax: 703.741.7698 / 800.377.1136 naadac@naadac.org www.naadac.org 40 Presented by Duane K.L. France, MA, MBA, LPC 14
Cultural competence needs to be seen as a continuum from basic cultural awareness to cultural competence; effort must be made to move beyond knowledge towards cultural sensitivity and competence (Adams, 1995). Developing sensitivity and understanding of another ethnic group Cultural awareness must be
4. Cultural Diversity 5. Cultural Diversity Training 6. Cultural Diversity Training Manual 7. Diversity 8. Diversity Training 9. Diversity Training Manual 10. Cultural Sensitivity 11. Cultural Sensitivity Training 12. Cultural Sensitivity Training Manual 13. Cultural Efficacy 14. Cultural Efficacy Training 15. Cultural Efficacy Training Manual 16.
include cultural awareness as part of military operations, battle preparations as well as military training and doctrine neglect the role of culture and religion. Cultural awareness is not currently included as part of foreign language training, and the cultural training provided to soldiers prior to
must be addressed through cultural awareness training. One way to affirm cultural differences in the classroom might be to establish collaboratives such as the intercultural collaboration of the Cultural Awareness Consortium (CAC), which provides high school students in Michigan opportunities to interact with students from various cultures.
that are language knowledge, language skills, affect, learning strategies, and cultural awareness. Cultural awareness is good for understanding language correctly and using language appropriately" (English Curriculum Standards, 2011). Therefore, one of the ultimate goals of English teaching is to train students to have cross-cultural awareness.
3 The cultural safety journey: An Australian nursing context 51 Odette Best Introduction 52 Developing the theory of cultural safety 52 The Australian context: Developing cultural awareness 54 Moving beyond cultural awareness to cultural sensitivity 62 The continuous journey towards cultural safety 63
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Awareness & Diversity Essential Cultural Self-Assessment Worksheet Collection A printable tool for helping increase multicultural awareness Lambers Fisher, LMFT, M.Div. Cultural Self-Assessment Worksheet #1: Multicultural Self-Awareness Multicultural awareness and diversity in
HIGH RISK BAKING Although most cakes and biscuits are classed as low risk products, some fillings and finishes are more high risk. Fresh cream, some cheese cakes and royal icing made from raw egg whites are all high risk and require extra thought to ensure they are prepared safely. Cakes that require refrigeration must be kept at or below 8 C at all times with limited time out of temperature .
