Dramaturgical Accounts of Transgender Individuals: Impression Management in the Presentation of Self to Specialist Gender Services.

Demand for gender dysphoria (GD) treatment has increased markedly over the past decade. Access to gender-affirming treatments is challenging for most people. For dysphoric individuals, much is at stake. Little is known about the specific needs, challenges, and coping strategies of this hard-to-reach group. We examined the experiences of treatment-seeking adolescents and adults using in-depth unstructured interviews with 26 people attending specialist gender services and 14 transgender people not referred to services. Patients with gender dysphoria distrust clinical services and describe considerable anxiety in sustaining their impression management strategies to obtain treatment. An authentic presentation is regarded by some participants, especially non-binary individuals, as inauthentic and emotionally difficult to maintain. Impression management strategies have partial success in accessing services. The presentation of "idealized" selves may result in unmet mental health needs of patients, and the receipt of interventions incongruent with their authentic selves.

The redundancy of positivism as a paradigm for nursing research.

New nursing researchers are faced with a smorgasbord of competing methodologies. Sometimes, they are encouraged to adopt the research paradigms beloved of their senior colleagues. This is a problem if those paradigms are no longer of contemporary methodological relevance. The aim of this paper was to provide clarity about current research paradigms. It seeks to interrogate the continuing viability of positivism as a guiding paradigm for nursing research. It does this by critically analysing the methodological literature. Five major paradigms are addressed: the positivist; the interpretivist/constructivist; the transformative; the realist; and the postpositivist. Acceptance of interpretivist, transformative or realist approaches necessarily entails wholesale rejection of positivism, while acceptance of postpositivism involves its partial rejection. Postpositivism has superseded positivism as the guiding paradigm of the scientific method. The incorporation in randomized controlled trials of postpositivist assumptions indicates that even on the methodological territory that it once claimed as its own, positivism has been rendered redundant as an appropriate paradigm for contemporary nursing research.

Nurse participation in legal executions: An ethics round-table discussion.

A paper was published in 2003 discussing the ethics of nurses participating in executions by inserting the intravenous line for lethal injections and providing care until death. This paper was circulated on an international email list of senior nurses and academics to engender discussion. From that discussion, several people agreed to contribute to a paper expressing their own thoughts and feelings about the ethics of nurses participating in executions in countries where capital punishment is legal. While a range of opinions were presented, these opinions fell into two main themes. The first of these included reflections on the philosophical obligations of nurses as caregivers who support those in times of great need, including condemned prisoners at the end of life. The second theme encompassed the notion that no nurse ever should participate in the active taking of life, in line with the codes of ethics of various nursing organisations. This range of opinions suggests the complexity of this issue and the need for further public discussion.

Service user engagement: A co-created interview schedule exploring mental health recovery in young adults.

AIM: The aim of this study was to co-create of an interview schedule exploring mental health recovery in collaboration with young adult service users. BACKGROUND: Service user involvement in research has been increasingly recognized as providing a vital authentic insight into mental health recovery. Engagement and collaboration with service users have facilitated the exploration of inaccessible or under-investigated aspects of the lived experience of mental health recovery, not only directing the trajectory of research, but making it relevant to their own contextual experience. DESIGN: A qualitative content analysis framework was employed in the co-creation of a semi-structured interview schedule through an engagement process with service users. METHODS: Two separate engagement groups took place at the premises of the service user organizations, between January - February 2014. Miles and Huberman's analysis framework was chosen for this phase as it enabled the visual presentation of factors, concepts or variables and the established relationship between them. RESULTS: The lived experience of mental ill health in young adulthood and how this was understood by others was a particularly relevant theme for participants. Further themes were identified between the impact of painful experiences at this developmental life stage leading to a deeper understanding of others through finding meaning in their own mental health recovery journey. CONCLUSION: Our findings identified that suffering painful experiences is an integral aspect in the process of mental health recovery. This understanding has particular relevance to mental health nursing practice, ensuring the care delivered is cognizant of the suffering or painful experiences that young adults are encountering.

The challenges and psychological impact of delivering nursing care within a war zone.

BACKGROUND: Between 2001 and 2014, British military nurses served in Afghanistan caring for both service personnel and local nationals of all ages. However, there have been few research studies assessing the psychological impact of delivering nursing care in a war zone hospital. PURPOSE: The purpose of the study was to explore the challenges and psychological stressors facing military nurses in undertaking their operational role. METHODS: A constructivist grounded theory was used. Semi-structured interviews were conducted with 18 British Armed Forces nurses at Camp Bastion Hospital, Afghanistan, in June to July 2013. DISCUSSION: Military nurses faced prolonged periods of caring for seriously injured polytrauma casualties of all ages, and there were associated distressing psychological effects and prolonged periods of adjustment on returning home. Caring for children was a particular concern. The factors that caused stress, both on deployment and returning home, along with measures to address these issues such as time for rest and exercise, can change rapidly in response to the dynamic flux in clinical intensity common within the deployable environment. CONCLUSION: Clinical training, a good command structure, the requirement for rest, recuperation, exercise, and diet were important in reducing psychological stress within a war zone. No formal debriefing model was advocated for clinical staff who appear to want to discuss traumatic incidents as a group, and this may have contributed to stigma and nurses feeling isolated. On returning home, military nurses reported being disconnected from the civilian wards and departments. The study raised the question of who cares for the carers, as participants reported a perception that others felt that they should be able to cope without any emotional issues. It is envisioned that the results are transferable internationally to nurses from other armed forces and will raise awareness with civilian colleagues.

Quality of nursing doctoral education in seven countries: survey of faculty and students/graduates.

AIMS: This study aimed to compare the findings of the quality of nursing doctoral education survey across seven countries and discuss the strategic directions for improving quality. BACKGROUND: No comparative evaluation of global quality of nursing doctoral education has been reported to date despite the rapid increase in the number of nursing doctoral programmes. DESIGN: A descriptive, cross-country, comparative design was employed. METHODS: Data were collected from 2007-2010 from nursing schools in seven countries: Australia, Japan, Korea, South Africa, Thailand, UK and USA. An online questionnaire was used to evaluate quality of nursing doctoral education except for Japan, where a paper version was used. Korea and South Africa used e-mails quality of nursing doctoral education was evaluated using four domains: Programme, Faculty (referring to academic staff), Resource and Evaluation. Descriptive statistics, correlational and ordinal logistic regression were employed. RESULTS: A total of 105 deans/schools, 414 faculty and 1149 students/graduates participated. The perceptions of faculty and students/graduates about the quality of nursing doctoral education across the seven countries were mostly favourable on all four domains. The faculty domain score had the largest estimated coefficient for relative importance. As the overall quality level of doctoral education rose from fair to good, the resource domain showed an increased effect. CONCLUSIONS: Both faculty and students/graduates groups rated the overall quality of nursing doctoral education favourably. The faculty domain had the greatest importance for quality, followed by the programme domain. However, the importance of the resource domain gained significance as the overall quality of nursing doctoral education increased, indicating the needs for more attention to resources if the quality of nursing doctoral education is to improve.

Quality of doctoral nursing education in the United Kingdom: exploring the views of doctoral students and staff based on a cross-sectional questionnaire survey.

AIM: To evaluate the quality of doctoral education in nursing in the United Kingdom. BACKGROUND: In recent decades, doctoral education programmes in nursing are increasing worldwide. There are many reasons for this and concerns have been raised regarding the quality of provision in and across countries. To date, the quality of doctoral education on a global level has not been reported in the literature. This United Kingdom study is part of a seven country investigation into the quality of doctoral education in nursing (Australia, Japan, Korea, South Africa, Thailand, United Kingdom and United States of America). DESIGN: A quantitative study using a cross-sectional comparative survey design. METHOD: An online survey was administered to collect the views of doctoral students and staff members on four domains: programme, faculty/staff, resource and evaluation. The study was carried out between 2010-2012. RESULTS: In most cases, staff perceived these more positively than students and the differences in perception were often statistically significant. Interestingly, many students rated the quality of supervision as excellent, whereas no staff member rated supervision this highly. The crucial importance of resources was confirmed in the path analysis of the four Quality of Doctoral Nursing Education domains. This demonstrates that investment in resources is much more cost-effective than investment in the other domains in relation to improving the overall quality of doctoral education in nursing. CONCLUSION: This study has wide-ranging implications for how the quality of doctoral education is monitored and enhanced.

'Familiarity' as a key factor influencing rural family carers' experience of the nursing home placement of an older relative: a qualitative study.

BACKGROUND: Admission to a nursing home is generally regarded as a stressful time for older people and their carers. Although the choice of home is significant in facilitating a more positive transition, few studies have explored this issue in detail, particularly in the context of rural communities. With a worldwide ageing population and an increasing demand for long-term care facilities, it is important to highlight the factors that can improve the experience of entry to long-term care and the role of nursing home staff in facilitating a more positive transition for older people and their families. METHODS: The overall aim of this qualitative study was to explore rural family carers' experience of the nursing home placement of an older relative. Semi structured interviews were conducted with 29 relatives of nursing home residents. Participants were selected from a large health and social care trust in the United Kingdom. Data were analysed using grounded theory principles and procedures and NVivo software. RESULTS: Rural family carers had a strong sense of familiarity with the nursing homes in their area and this appeared to permeate all aspects of their experience. Carers who reported a high degree of familiarity appeared to experience a more positive transition than others. This familiarity was influenced by the high degree of social capital that was present in the rural community where the study was conducted. This familiarity, in turn, influenced the choice of nursing home and the responses of family carers. The theory that emerged suggests that familiarity was the key factor influencing rural family carers' experience of the nursing home placement of an older relative. CONCLUSIONS: The population of the world is ageing and nursing homes are increasingly providing care to older people with multiple and complex needs. This study makes an important contribution to the ways in which the move to long term care can be managed more effectively by increasing awareness of the importance of familiarity, stability and social capital in the lives of older people and their carers.

Investigating the role of the general practitioner in cancer prevention: a mixed methods study.

BACKGROUND: Despite evidence of the effectiveness of cancer preventive services and the increasing development of guidelines, actual rates of delivery of cancer prevention activities remain low. Due to their frequent front-line contact with the public, family physicians (GPs) have the potential to play an important role in the primary prevention of cancer. However, there is a lack of information about their actual role in cancer prevention. The aim of this study was to investigate the actual and potential roles of general practitioners (GP) in the prevention of cancer. METHODS: A sequential exploratory mixed methods approach was used. The sample included all the General Practice (GP) practices in a region in the UK (n=345). Postal questionnaires were administered to GPs (n=1249); following 290 returns (response rate 23%), semi-structured interviews were undertaken with GPs (n=14). RESULTS: The majority of the GP respondents (66.4%, n=184) considered that they routinely provided cancer prevention information. This was specifically focusing on smoking cessation as almost all GPs (96.8%, n=270) enquired about a patient's smoking status. Overall, 47.2% (n=128) of GP respondents indicated that they felt they did not have time to perform a cancer prevention role; however, 88.3% (n=242) still felt that they had the 'opportunity' to do so. Over half the sample (61.3%, n=168) indicated that imposed health priorities and targets militated against providing cancer prevention activities. Almost all the GP respondents (98.9%, n=273) agreed with empowering individuals to take responsibility for their health issues. The GPs identified the need for alternative models for cancer prevention beyond current face to face patient care, including other health and non-health professionals. Whilst lack of time was identified as a critical factor, the GPs indicated that significant efforts were made to encourage patients to take personal responsibility for lifestyle choices. CONCLUSIONS: The GPs indicated a need for training around behavioural change and theories of motivation and action. This has implications for primary care and family physicians worldwide. While doctor-patient consultations and the physicians' credibility offer great potential for cancer prevention, time pressures and imposed government targets often mean that their actual cancer prevention role is reduced.

Perceptions of the unregistered healthcare worker's role in pre-registration student nurses' clinical training.

AIM: To explore the unregistered healthcare worker's role and influence on student nurses' clinical learning experience. BACKGROUND: Across the developed world, the role of the unregistered worker is exceeding its traditional boundaries. Evidence suggests that this includes the day-to-day mentoring of pre-registration student nurses. However, no research to date has explored reasons as to why this is occurring, what types of tasks are taught, and the consequence of this. DESIGN: A sequential exploratory mixed method research design was adopted. METHOD: Reporting on the final qualitative phase of a mixed method sequential research study, semi-structured interviews were undertaken with 59 unregistered healthcare workers across four hospitals in Northern Ireland. Transcriptions were analysed using a content analysis approach; all data were collected in 2010. RESULTS: Findings show the diversity of the unregistered healthcare workers' roles and confirm that they play a major part in the education of student nurses with regards to basic, clinical, and non-clinical tasks, with and without the approval of registered staff. However, their involvement did not reflect their levels of expertise as evidenced by certified training. Their participation was justified based on mentor unavailability, their closeness to the student and the patient. While some did raise concerns, they recommended that these workers be formally involved in nurse education. CONCLUSION: Mechanisms of workforce planning need to pay particular attention to the expanding role of unregistered healthcare workers as 'role drift' has the potential to alter patterns of work and affect current educational approaches impacting on the acquisition of clinical skills. Further research is recommended in this domain.

Quality of life in men receiving radiotherapy and neo-adjuvant androgen deprivation for prostate cancer: results from a prospective longitudinal study.

AIM: To report a study measuring the quality of life and side effects in men receiving radiotherapy and hormone ablation for prostate cancer up to 1 year after treatment. BACKGROUND: Prostate cancer incidence is increasing with the result that more men are living longer with the disease and the side effects of treatment. It is important to know the effects this has on their quality of life. DESIGN: Survey. METHOD: Between September 2006-September 2007, all men who were about to undergo radical conformal radiotherapy ± neo-adjuvant androgen deprivation for localized prostate cancer were invited to participate in the study; 149 men were recruited. They completed the European Organization on Research and Treatment of Cancer quality of life questionnaire C-30 and Prostate Cancer module PR25 at four time-points. RESULTS: At 4-6 weeks after radiotherapy, participants experienced the biggest relative decline in global quality of life, social, physical, and role functioning and an increase in treatment side effects. At 6 months postradiotherapy the majority of men experienced an improvement in their side effects. However, a minority of men were experiencing severe side effects of radiotherapy at 1 year post-treatment. Single men and men who had a low quality of life prior to radiotherapy, reported a lower quality of life at 1 year after treatment in comparison to married men. CONCLUSION: Men with prostate cancer suffer limitations due to the symptoms they experience and disruption to their quality of life. It is essential that nurses develop and deliver follow-up care which is flexible and appropriate to the individual needs of these men.

Exploring and comparing the experience and coping behaviour of men and women with colorectal cancer after chemotherapy treatment: a qualitative longitudinal study.

OBJECTIVES: Men have higher incidence and mortality rates for nearly all cancers. They are less likely than women to utilise cancer information services and other social support services. The aim of this study was to explore and compare the experience and coping behaviour of men and women after treatment for colorectal cancer (CRC). METHODS: A longitudinal qualitative study was conducted involving 38 individuals (24 men and 14 women) with CRC. Data were generated using semi-structured interviews at four time points over an 18-month period, post-diagnosis. Interviews focused on participant's experience of CRC and on how gender affected their coping. This paper reports the findings of interviews 3 and 4 which examined the participant's experience after chemotherapy. RESULTS: Three themes emerged from the interviews ('new normal', living with uncertainty and support needs). Many men and women reacted similarly; however, there was some variation evident between and within sexes. The main difference was with regard to the long-term physical side effects of the illness. Many women admitted to still experiencing side effects, whereas many men indicated that they had no problems. These men engaged in practices that aligned with their gender identity and view of masculinity. It must be noted that some men and women were still experiencing an impact. CONCLUSIONS: Recovery from the physical and psychological effects of CRC does not occur simultaneously. Healthcare professionals should be aware that not all men (or women) conform to the social stereotypes of masculinity (or femininity).

Providing meaningful care: learning from the experiences of suicidal young men.

Little is known about young suicidal men's preferences for care. Using a broad interpretive approach, we interviewed 36 formerly suicidal young men in a study addressing the development and provision of mental health services. Our analysis yielded three core categories: widening access and bolstering proactive outreach, on becoming a man, and equipping young men for future challenges. Collectively, these categories suggest key features and processes of appropriate service configuration and clinical care: (a) services that reach out proactively serve to encourage young men's initial and ongoing engagement; (b) care delivered over the long term ensures a necessary focus on a meaningful future life; (c) mental health professionals (MHPs) are centrally involved alongside significant others, including those with personal experience of suicide; and (d) the development of a vital interpersonal connection is based on MHPs actively communicating their empathy, open-mindedness, and interest in a young man's unique biography.

Research Quality-Lessons from the UK Research Excellence Framework (REF) 2021.

Research quality is a term often bandied around but rarely clearly defined or measured [...].

Doctoral education, advanced practice and research: An analysis by nurse leaders from countries within the six WHO regions.

Doctoral education, advanced practice and research are key elements that have shaped the advancement of nursing. Their impact is augmented when they are integrated and synergistic. To date, no publications have examined these elements holistically or through an international lens. Like a three-legged stool they are inter-reliant and interdependent. Research is integral to doctoral education and influential in informing best practice. This significance and originality of this discussion paper stem from an analysis of these three topics, their history, current status and associated challenges. It is undertaken by renowned leaders in 11 countries within the six World Health Organisation (WHO) regions: South Africa, Egypt, Finland, United Kingdom, Brazil, Canada, United States, India, Thailand, Australia, and the Republic of Korea. The first two authors used a purposive approach to identify nine recognized nurse leaders in each of the six WHO regions. These individuals have presented and published papers on one or more of the three topics. They have led, or currently lead, large strategic organisations in their countries or elsewhere. All these accomplished scholars agreed to collect relevant data and contribute to the analysis as co-authors. Doctoral education has played a pivotal role in advancing nurse scholarship. Many Doctor of Philosophy (PhD) prepared nurses become faculty who go on to educate and guide future nurse researchers. They generate the evidence base for nursing practice, which contributes to improved health outcomes. In this paper, the development of nursing doctoral programmes is examined. Furthermore, PhDs and professional doctorates, including the Doctor of Nursing Practice, are discussed, and trends, challenges and recommendations are presented. The increasing number of advanced practice nurses worldwide contributes to better health outcomes. Nonetheless, this paper shows that the role remains absent or underdeveloped in many countries. Moreover, role ambiguity and role confusion are commonplace and heterogeneity in definitions and titles, and regulatory and legislatorial inconsistencies limit the role's acceptance and adoption. Globally, nursing research studies continue to increase in number and quality, and nurse researchers are becoming partners and leaders in interdisciplinary investigations. Nonetheless, this paper highlights poor investment in nursing research and a lack of reliable data on the number and amount of funding obtained by nurse researchers. The recommendations offered in this paper aim to address the challenges identified. They have significant implications for policy makers, government legislators and nurse leaders.

Exploring and comparing the experience and coping behaviour of men and women with colorectal cancer at diagnosis and during surgery.

AIM: This paper is a report of a study exploring and comparing the experience of men and women with colorectal cancer at diagnosis and during surgery. BACKGROUND: Men have higher incidence and mortality rates for nearly all cancers and frequently use health behaviours that reflect their masculinity. There has been minimal investigation into the influence of gender on the experience of a 'shared' cancer. METHODS: From November 2006 to November 2008, a qualitative study was conducted involving 38 individuals (24 men, 14 women) with colorectal cancer. Data were generated using semi-structured interviews at four time points over an 18-month period. This paper reports the participants' experience at diagnosis and during surgery (time point 1) with the purpose of examining the impact of gender on this experience. FINDINGS: In general, men appeared more accepting of their diagnosis. The majority of females seemed more emotional and more affected by the physical side effects. However, there was variation in both gender groups, with some men and women portraying both 'masculine' and 'feminine' traits. There was also individual variation in relation to context. CONCLUSIONS: It appears that many men may have been experiencing side effects and/or psychological distress that they were reluctant to discuss, particularly as some men portrayed typical 'masculine' traits in public, but felt able to open up in private. Nurses should not make assumptions based on the traditional view of masculinity, and should determine how each man wants to deal with their diagnosis and not presume that all men need to 'open up' about their illness.

Analysis of international content of ranked nursing journals in 2005 using ex post facto design.

AIM: The purpose of this study was to examine articles in ISI-ranked nursing journals and to analyse the articles and journals, using definitions of international and article content. BACKGROUND: Growing emphasis on global health includes attention on international nursing literature. Contributions from Latin America and Africa have been reported. Attention to ranked nursing journals to support scholarship in global health is needed. METHOD: Using an ex post facto design, characteristics of 2827 articles, authors and journals of 32 ranked nursing journals for the year 2005 were analysed between June 2006 and June 2007. Using definitions of international and of article content, research questions were analysed statistically. FINDINGS: (a) 928 (32·8%) articles were international; (b) 2016 (71·3%) articles were empirical or scholarly; (c) 826 (89·3%) articles reflecting international content were scholarly or empirical; (d) among international articles more were empirical (66·3 % vs. 32·8 %; χ(2) ((1)) = 283·6, P < 0·001); (e) among non-international articles more were scholarly (29·2 % vs. 22·7 %; χ(2) ((1)) = 15·85, P < 0·001; 22·7 %); (f) 1004 (78·0 %) articles were international, based on author characteristics; (f) 20 (62·5 %) journals were led by an international editorial team; and (g) international journals had more international articles (3·6 % vs. 29·2 %; χ(2) ((1)) = 175·75, P < 0·001) and higher impact factors than non-international journals (t = -14·43, P < 0·001). CONCLUSION: Articles with empirical content appear more frequently in international journals. Results indicate the need to examine the international relevance of the nursing literature.

"Surviving out of the Ashes" - An exploration of young adult service users' perspectives of mental health recovery.

WHAT IS KNOWN ON THE SUBJECT?: The conceptual components of mental health recovery have been proposed, however, the barriers to their sustainability within the context of internal and external stressors require further exploration. Within their emerging adult role, young people will experience the personal challenges that will directly impact their understanding of their recovery, which will be different from other age groups. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Findings revealed recovery is understood as an uncharted, timely and personal process of engaging and transcending pain. Perceived barriers to mental health recovery and the internal dynamics experienced within the process have been explored. Recovery in young adulthood involved the reclaiming of their active and purposeful life force. It acquires real-life relevance when applied to the social and cultural factors that provide meaning in life for young adults. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This research will impact how mental health nurses understand the catalytic effects of personal, social and cultural meaning of suffering in young adults' actualization of mental health recovery. Findings have significance for practice as the process of mental health recovery must not be presented as a clinical pathway, but understood as a personalized strategy of individual wellness in young adulthood. ABSTRACT: INTRODUCTION: Within their emerging adult role, young people will embark on employment, form intimate relationships and live independently. This indicates that how recovery is experienced and actualized in young adulthood may be different from other age groups. AIM/QUESTION: To explore young adult service user's perspectives of mental health recovery in Northern Ireland. METHOD: Semi-structured individual qualitative interviews were analysed using a Gadamerian-based hermeneutic method and interpreted using a novel theoretical framework. The sample comprised 25 participants with an average age of 28 years. FINDINGS: Five key themes evolved: Services: A Losing Battle Straight Away; From your Foundations to a Step in the Dark; Let Go of the Pain not the Experience; Surviving Out of the Ashes Recovery; and Needs to be More than a Word. DISCUSSION: The main findings were that recovery involved the reclaiming of their active and purposeful life force. It is suggested that young adults have developed an explanatory model of "use that stuff you wanna bury" to transform an illness narrative to a wellness strategy. IMPLICATIONS FOR PRACTICE: This research has implications for mental health nursing so the process of mental health recovery is not presented as a clinical pathway, but a personalized strategy of individual wellness.

Benchmarks for effective primary care-based nursing services for adults with depression: a Delphi study.

AIM: This paper is a report of a study conducted to identify and gain consensus on appropriate benchmarks for effective primary care-based nursing services for adults with depression. BACKGROUND: Worldwide evidence suggests that between 5% and 16% of the population have a diagnosis of depression. Most of their care and treatment takes place in primary care. In recent years, primary care nurses, including community mental health nurses, have become more involved in the identification and management of patients with depression; however, there are no appropriate benchmarks to guide, develop and support their practice. METHOD: In 2006, a three-round electronic Delphi survey was completed by a United Kingdom multi-professional expert panel (n = 67). FINDINGS: Round 1 generated 1216 statements relating to structures (such as training and protocols), processes (such as access and screening) and outcomes (such as patient satisfaction and treatments). Content analysis was used to collapse statements into 140 benchmarks. Seventy-three benchmarks achieved consensus during subsequent rounds. Of these, 45 (61%) were related to structures, 18 (25%) to processes and 10 (14%) to outcomes. CONCLUSION: Multi-professional primary care staff have similar views about the appropriate benchmarks for care of adults with depression. These benchmarks could serve as a foundation for depression improvement initiatives in primary care and ongoing research into depression management by nurses.