Examining cultural adaptations of the savvy caregiver program for Korean American caregivers using the framework for reporting adaptations and modifications-enhanced (FRAME).

BACKGROUND: The Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) is a tool that systematically guides decision-making and reporting of adaptations made to evidence-based interventions. Using FRAME, we documented the process and outcomes of adapting the Savvy Caregiver Program (SCP) for Korean American dementia caregivers. METHODS: Sequential adaptation was initiated with linguistic attunement, followed by pilot implementation and full adaptation. Our data-driven adaptation with multiple data sources and a feedback loop among multiple stakeholders yielded a total of 32 modifications, and each was coded according to the eight domains of FRAME: (1) what was modified, (2) who participated in recommending and deciding the modification to be made, (3) when the modification occurred, (4) whether the modification was planned, (5) whether the modification was fidelity-consistent, (6) whether the modification was temporary, (7) at what level of delivery, the modification was made, and (8) why the modification was made. RESULTS: The areas of adaptation were evenly distributed across context (37.5%), content (31.2%), and training (31.2%). The primary reasons for modification were for engagement (62.5%), followed by fit with recipients (43.8%) and outcome improvement (31.1%). About 66% of the modifications were applied to the entire target group, and all modifications were fidelity-consistent. CONCLUSIONS: The FRAME categorization provided a detailed understanding of the process and nature of adapting the SCP and served as a foundation for further implementation and scale-up. FRAME not only serves as a guide for adapting evidence-based interventions but also promotes their replicability and scalability.

Evaluation of a Photo Captioning Cognitive Empathy Intervention for Dementia Caregivers.

OBJECTIVES: The goal of this study was to develop and evaluate an intervention aimed at increasing cognitive empathy, improving mental health, and reducing inflammation in dementia caregivers, and to examine the relevant neural and psychological mechanisms. METHODS: Twenty dementia caregivers completed an intervention that involved taking 3-5 daily photographs of their person living with dementia (PLWD) over a period of 10 days and captioning those photos with descriptive text capturing the inner voice of the PLWD. Both before and after the intervention, participants completed questionnaires, provided a blood sample for measures of inflammation, and completed a neuroimaging session to measure their neural response to viewing photographs of their PLWD and others. RESULTS: 87% of enrolled caregivers completed the intervention. Caregivers experienced pre- to post-intervention increases in cognitive empathy (i.e. Perspective-Taking) and decreases in both burden and anxiety. These changes were paralleled by an increased neural response to photographs of their PLWD within brain regions implicated in cognitive empathy. CONCLUSION: These findings warrant a larger replication study that includes a control condition and follows participants to establish the duration of the intervention effects. CLINICAL IMPLICATIONS: Cognitive empathy interventions may improve caregiver mental health and are worthy of further investigation.

Changes in Depressive Symptoms of Korean American Dementia Caregivers After Attending the Savvy Caregiver Program: Preliminary Findings with a Pilot Sample.

OBJECTIVES: Language accommodation is indispensable in making evidence-based interventions available and accessible to ethnic minorities with limited English proficiency. As part of the larger effort to culturally adapt the Savvy Caregiver Program for Korean American dementia caregivers, we first conducted linguistic adaptation, and the present study reports the preliminary findings on participants' changes in depressive Symptoms. METHODS: The linguistically adapted program was delivered to two small groups of Korean American dementia caregivers (total n = 13) by two Savvy-certified Korean-speaking trainers. Participants' depressive symptoms were assessed at three time points (pre-intervention, immediate post-intervention, and 6-month follow-up). RESULTS: Following the intervention, participants exhibited lowered depressive symptoms (t = 8.64, p < .001, Cohen's d = .89). This benefit was sustained at 6-month follow-up. CONCLUSIONS: Findings suggest that the therapeutic benefit of the Savvy Caregiver Program could potentially be shared with linguistic minorities when delivered in their native language. CLINICAL IMPLICATIONS: Although limited in its scope and nature, the pilot study with linguistic adaptation sheds light on efforts to close the gap in the evidence-based intervention delivery.

The development of task sharing policy and guidelines in Kenya.

BACKGROUND: The global critical shortage of health workers prevents expansion of healthcare services and universal health coverage. Like most countries in sub-Saharan Africa, Kenya's healthcare workforce density of 13.8 health workers per 10,000 population falls below the World Health Organization (WHO) recommendation of at least 44.5 doctors, nurses, and midwives per 10,000 population. In response to the health worker shortage, the WHO recommends task sharing, a strategy that can increase access to quality health services. To improve the utilization of human and financial health resources in Kenya for HIV and other essential health services, the Kenya Ministry of Health (MOH) in collaboration with various institutions developed national task sharing policy and guidelines (TSP). To advance task sharing, this article describes the process of developing, adopting, and implementing the Kenya TSP. CASE PRESENTATION: The development and approval of Kenya's TSP occurred from February 2015 to May 2017. The U.S. Centers for Disease Control and Prevention (CDC) allocated funding to Emory University through the United States President's Emergency Plan for AIDS Relief (PEPFAR) Advancing Children's Treatment initiative. After obtaining support from leadership in Kenya's MOH and health professional institutions, the TSP team conducted a desk review of policies, guidelines, scopes of practice, task analyses, grey literature, and peer-reviewed research. Subsequently, a Policy Advisory Committee was established to guide the process and worked collaboratively to form technical working groups that arrived at consensus and drafted the policy. The collaborative, multidisciplinary process led to the identification of gaps in service delivery resulting from health workforce shortages. This facilitated the development of the Kenya TSP, which provides a general orientation of task sharing in Kenya. The guidelines list priority tasks for sharing by various cadres as informed by evidence, such as HIV testing and counseling tasks. The TSP documents were disseminated to all county healthcare facilities in Kenya, yet implementation was stopped by order of the judiciary in 2019 after a legal challenge from an association of medical laboratorians. CONCLUSIONS: Task sharing may increase access to healthcare services in resource-limited settings. To advance task sharing, TSP and clinical practice could be harmonized, and necessary adjustments made to other policies that regulate practice (e.g., scopes of practice). Revisions to pre-service training curricula could be conducted to ensure health professionals have the requisite competencies to perform shared tasks. Monitoring and evaluation can help ensure that task sharing is implemented appropriately to ensure quality outcomes.

Cultural adaptation of the savvy caregiver program for Korean Americans with limited English proficiency: a feasibility and acceptability study.

BACKGROUND: Limited English proficiency (LEP) of dementia caregivers poses a critical barrier to these caregivers' access to evidence-based interventions. In an effort to make such interventions available and accessible to dementia caregivers with LEP, in the present study we use Barrera and colleagues' (2011) three-step model of cultural adaptation: (1) information gathering, (2) preliminary adaptation, and (3) full adaptation. Selecting Korean Americans as a target group and the Savvy Caregiver Program (SCP) as a target intervention, we demonstrate the sequential process of cultural adaption and report the outcomes on feasibility and acceptability. METHODS: Preliminary adaptation with linguistic attunement was conducted by translating the SCP manual into Korean and certifying two lay individuals who were bilingual in English and Korean as Savvy trainers. The 6-week online SCP program was delivered by the two trainers in Korean with six to seven caregiver participants per trainer (N = 13). Feasibility and acceptability of the SCP for both caregiver participants and trainers were assessed using mixed methods, and their data then informed full adaptation. RESULTS: Findings not only showed the initial efficacy of the linguistically attuned SCP but also suggested areas for further modification. Data-driven assessment yielded a list of recommended changes for full adaptation, which was reviewed by the SCP developer to ensure fidelity and by community and research partners to confirm contextual and cultural relevance. CONCLUSIONS: The adopted changes are broadly summarized as representing logistical, technical, and cultural issues. Given our refined set of educational materials and implementation guidelines, we discuss future directions for research and development.

Attention control in a trial of an online psychoeducational intervention for caregivers.

In reports of randomized controlled trials, thorough description of the attention control condition has been recommended, yet is frequently lacking. The Tele-Savvy Caregiver program for informal caregivers of persons living with dementia was tested in a randomized controlled trial with an attention control condition. The purpose of this trial was to test Tele-Savvy's efficacy in reducing the negative effects of caregiving on caregivers, promoting quality of life for persons living with dementia, and improving caregiver mastery. We describe the design and implementation of and examine the outcomes associated with the attention control condition. Caregivers were randomized to the immediate Tele-Savvy (active condition), Healthy Living (attention control), or waitlist. The attention control content was focused on healthy lifestyle and was not intended to affect the outcomes that Tele-Savvy targeted. The attention control group was similar to Tele-Savvy in the intervention structure and duration: it consisted of seven weekly group videoconferences and 36 video lessons. Data on outcomes of caregivers and persons living with dementia were collected at baseline and 3 and 6 months postbaseline. Multilevel mixed effects models were used to determine changes in the outcomes. One hundred and eleven caregivers were randomized to the attention control condition (attrition 21.6%). Eighteen formative assessment interviews focusing on caregivers' experience in the attention control condition were conducted. The attention control condition completers had no statistically significant changes in the variables that Tele-Savvy targeted. These results may be used in the design and implementation of attention control conditions in behavioral intervention research.

Factors associated with postpartum contraception in Togo, West Africa.

The health benefits of postpartum contraception are well established. Using 2013/14 Togo Demographic and Health Survey (DHS) data, we examine the association between contraceptive use among women who gave birth within 24 months of the DHS and four health service use indicators - antenatal care, institutional delivery, postpartum care, and immunization of the last child - in addition to socio-demographic factors. Factors associated with postpartum contraceptive use in Togo included having their last birth in a health facility, having a postnatal check within two months of birth, youngest child receiving the first diphtheria-pertussis-tetanus vaccine, wanting to space children more than two years from last birth or not have more children, living outside the Savanes region, husband's desire for number of children agreeing with the woman's, and increasing breastfeeding duration. These findings highlight the need for programming which strengthens the integration of contraception into reproductive and immunization services in Togo.

Caregiver self-efficacy improves following complex care training: Results from the Learning Skills Together pilot study.

Family caregivers to persons living with dementia increasingly provide complex care tasks, though most (53%) do so without any training. "Complex care" includes medical/nursing tasks, as well as personal care tasks that require disease knowledge. Of the 67% of dementia caregivers who provide complex care, nearly half worry about making a mistake. To help caregivers feel more confident when providing complex care tasks, we developed and conducted a pilot study of the 4-week Learning Skills Together psychoeducation program (LST; N=35). Participants in LST reported high satisfaction with the program and found the information shared about complex care was easy to understand. Pre- and post-test data demonstrated improvements in mean caregiver self-efficacy at both 4-weeks and 8-weeks post-intervention (mean difference (MD)=1.0, SD= 1.6, p-value=0.004 and MD= 1.0, SD=2.2, p-value=0.038, respectively). Results demonstrate the potential for a brief psychoeducational program to prepare caregivers to provide complex care to persons living with dementia.

Experiences of Black American Dementia Caregivers During the COVID-19 Pandemic.

Dementia caregivers are responsible for the daily care and management of individuals who are among the most vulnerable to the serious consequences of COVID-19. This qualitative study explores the experience of Black dementia caregivers during the COVID-19 pandemic in the United States. Nineteen Black dementia caregivers were recruited to participate in semi-structured focus groups held in April 2021. Four overarching themes were constructed during analysis: social isolation, decreased well-being, the good and bad of telehealth, and challenges fulfilling health care needs. The results indicate the experience of Black dementia caregivers overlaps with existing literature on the experiences of dementia caregivers of other races during COVID-19. These results can assist in addressing the specific needs and improving the experiences of dementia caregivers in current and future public health crises.

Is Social Isolation Related to Emotion Dysregulation and Retention in Care Among Older Persons Living with HIV?

Retention in care is important in managing HIV among older persons living with HIV (PLWH). We used Theory of Loneliness-loneliness affects emotion-regulatory processes which lead to dysfunctional health behaviors-to test whether social isolation is related to retention in care either directly or indirectly through emotion dysregulation in older PLWH (≥ 50 years of age; N = 144). Retention in care was defined as the proportion of attended scheduled medical visits; visit data were collected prospectively over 12 months from electronic medical records. Self-reported social isolation, emotion dysregulation, and covariates were assessed cross-sectionally at baseline. Most participants were male (60%), African American/Black (86%), and single (59%); 56% were optimally retained in care. Retention was related to monthly income, CD4 + T cell count, and drug use with no direct or indirect effects of social isolation on retention in care. Socioeconomic and behavioral vulnerabilities are closely related to retention in care among older PLWH.

RESUMEN: Retención en atención médica es importante para el manejo de VIH con personas mayores que viven con VIH (PMVV). Nosotros usamos la Teoría de Soledad- soledad afecta los procesos que regulan emociones y crea comportamientos de salud disfuncionales- para probar si aislamiento social está asociado directamente o indirectamente con la retención en atención médica por desregular emociones en PMVV (≥ 50 años de edad; N = 144). Retención en atención médica fue definido por la proporción de visitas médicas programadas y atendidas; y los datos de visitas atendidas que fueron programadas fueron recopilados prospectivamente por 12 meses de archivos médicos electrónicos. Aislamiento social auto-reportado, desregulación emocional, y covariables fueron evaluados transversalmente de la línea de base. La mayoría de los participantes fueron masculinos (60%), negros/americanos africanos (86%) y solteros (59%); 56% de nuestra muestra fueron retenidos optimamente en atención médica. Retención en atención médica fue asociada con ingresos mensuales, el conteo de linfocitos cd4 + , y el consumo de drogas ilegales; no encontramos efectos directos ni indirectos del aislamiento social a la retención en atención médica. Vulnerabilidades socioeconómicas y de comportamiento están vinculados estrechamente a la retención en atención médica para PMVV.

Correlates of loneliness in older persons living with HIV.

Loneliness poses a significant risk for morbidity and mortality in the context of older adulthood. Research shows that older persons living with HIV (PLWH) often face increased and complex vulnerability in terms of physical and psychosocial needs which may promote loneliness. The current study sought to identify correlates of loneliness in a sample of 146 older PLWH (age ≥50) recruited from an outpatient HIV clinic in Atlanta, GA. Participants completed a survey on loneliness, depression, HIV-related stigma, social network size, HIV-disclosure status, disease burden, and demographics. HIV biomarkers were abstracted from electronic medical records. Participants were predominantly male (60%) and African American (86%). Twelve percent (n = 17) reported past homelessness/unstable housing. Multivariable modeling revealed that depression and HIV-related stigma explained 41% of the variance in loneliness, above and beyond the effects of past homelessness/unstable housing and disease burden (R2 = 0.41, F(7, 138) = 13.76, p < .001). Findings suggest that targeting HIV-related stigma and depression may reduce loneliness in older PLWH, but more studies are needed to elucidate causal pathways. A greater understanding of the mechanisms by which loneliness affects health among older PLWH could help better inform efforts to improve health in this patient population.

The ResidentialCare Transition Module: a single-blinded randomized controlled evaluation of a telehealth support intervention for family caregivers of persons with dementia living in residential long-term care.

BACKGROUND: Families do not fully disengage from care responsibilities following relatives' admissions to residential long-term (RLTC) care settings such as nursing homes. Caregiver stress, depression, or other key outcomes remain stable or sometimes increase following a relative's RLTC entry. Some interventions have attempted to increase family involvement after institutionalization, but few rigorous studies have demonstrated whether these interventions are effective in helping families navigate the potential emotional and psychological upheaval presented by relatives' transitions to RLTC environments. The Residential Care Transition Module (RCTM) provides six formal sessions of consultation (one-to-one and family sessions) over a 4-month period to family caregivers who have admitted a relative to a RLTC setting. METHODS: In this embedded mixed methods randomized controlled evaluation, family members who have admitted a cognitively impaired relative to a RLTC setting are randomly assigned to the RCTM (n = 120) or a usual care control condition (n = 120). Primary outcomes include reductions in family members' primary subjective stress and negative mental health outcomes; secondary role strains; and residential care stress. The mixed methods design will allow for an analysis of intervention action mechanisms by "embedding" qualitative components (up to 30 semi-structured interviews) at the conclusion of the 12-month evaluation. DISCUSSION: This evaluation will fill an important clinical and research gap by evaluating a psychosocial intervention designed for families following RLTC admission that determines whether and how the RCTM can help families better navigate the emotional and psychological challenges of residential care transitions. TRIAL REGISTRATION: ClinicalTrials.gov (NCT02915939, prospectively registered).

Patient and caregiver outcomes at the integrated memory care clinic.

The purpose of this longitudinal cohort study was to explore the outcomes of persons living with dementia (PLWD) and their caregivers during their first 9 months at the Integrated Memory Care Clinic (IMCC). IMCC advanced practice registered nurses provide dementia care and primary care simultaneously and continuously to PLWD until institutionalization. Changes were examined in caregivers' psychological well-being (perceived stress, depressive symptoms, caregiver burden, and anxiety) and health status and in PLWDs' quality of life and neuropsychiatric symptoms. Data were collected at baseline, then 3 and 6 months post-baseline. Forty-two caregivers completed all 3 assessments. Most variables remained unchanged. Statistically significant improvements in 5 sub-scales of the Neuropsychiatric Inventory were observed: caregivers' distress regarding their PLWDs' delusions and anxiety, and PLWDs' severity of delusions, depression, and total symptom severity. Further testing of the IMCC is required, including in quasi-experimental studies, to determine its efficacy.

Exercise and Cognitive Training as a Strategy to Improve Neurocognitive Outcomes in Heart Failure: A Pilot Study.

OBJECTIVE: Mild cognitive impairment, especially memory loss, is prevalent in patients with heart failure (HF) and contributes to poor clinical outcomes and higher mortality. METHODS: This study evaluated a combined aerobic exercise and cognitive training (EX/CT) program on memory, executive function, attention, processing speed and reaction time compared to exercise only or a usual care attention control (UCAC) stretching and flexibility program. Participants completed a standardized neurocognitive battery at baseline, 3 months, and 6 months along with demographic, clinical, and functional capacity (6-minute walk test). A linear mixed model analysis was used with comorbidity as a covariate. RESULTS: Sixty-nine participants were enrolled, the mean age was 61 ± 10 years, 54% were women, 55% were African American, and the mean left ventricular ejection fraction percentage was 35 ± 15. A significant group by time interaction for verbal memory was found at 3 months (F [2, 53] = 4.3, p = 0.018) but was not sustained at 6 months in the EX/CT group. Processing speed/attention differed across treatment groups between baseline and 6 months, but improvement occurred among UCAC participants. There were also significant group differences in the 6MWT distance occurring at 3 months (F [2, 52] = 3.5, p = 0.036); however, significant improvement was observed within the EX/CT group only. There were no significant differences in 6MWT in the other groups at 3 or 6 months. CONCLUSION: An EX/CT intervention was associated with improved memory in persons with HF and warrants further investigation in a larger trial. The relationship between functional capacity and cognitive function also needs further study.

Dementia-friendly faith village worship services to support African American families: Research protocol.

African American caregivers for persons living with dementia frequently experience emotional strain, burden, social isolation, and depression. One source of support for them when in distress is their church community. However, many African American churches do not have programs to support families and congregants living with dementia. Dementia often restricts persons living with dementia and their caregivers from attending church. Both become increasingly uncomfortable in church settings due to fear of embarrassment, uncertainty about the behavior of the person living with dementia, and shame. Church attendance and religion has been shown to be beneficial for caregivers and elders living with dementia. However, there is little work exploring how involvement in religious practices together (caregivers and persons living with dementia) might enhance the quality of life for these families. This protocol is written to detail the designing and testing of the feasibility and preliminary efficacy of a dementia-friendly faith village worship service. In the study, we will examine how dementia-friendly faith village worship services support the well-being of caregivers and care recipients in three African American churches through observation, interviews, and surveys. A sample of 30 dyads of African American caregivers and persons living with dementia will be asked to attend six modified worship services together over 6 months. In this study, we hope to demonstrate the significant role of churches in the lives of African American family caregivers and persons living with dementia and show that a faith-based, family-oriented approach can promote a greater quality of life for African American families living with dementia.

Evaluation of the impact of the ARC program on national nursing and midwifery regulations, leadership, and organizational capacity in East, Central, and Southern Africa.

BACKGROUND: The African Health Professions Regulatory Collaborative (ARC) was launched in 2011 to support countries in East, Central, and Southern Africa to safely and sustainably expand HIV service delivery by nurses and midwives. While the World Health Organization recommended nurse initiated and managed antiretroviral therapy, many countries in this region had not updated their national regulations to ensure nurses and midwives were authorized and trained to provide essential HIV services. For four years, ARC awarded annual grants, convened regional meetings, and provided technical assistance to country teams of nursing and midwifery leaders to improve national regulations related to safe HIV service delivery. We examined the impact of the program on national regulations and the leadership and organizational capacity of country teams. METHODS: Data was collected to quantify the level of participation in ARC by each country (number of grants received, number of regional meetings attended, and amount of technical assistance received). The level of participation was analyzed according to two primary outcome measures: 1) changes in national regulations and 2) improvements in leadership and organizational capacity of country teams. Changes in national regulations were defined as advancement of one "stage" on a capability maturity model; nursing and midwifery leadership and organizational capacity was measured by a group survey at the end of the program. RESULTS: Seventeen countries participated in ARC between 2012 and 2016. Thirty-three grants were awarded; the majority addressed continuing professional development (20; 61%) and scopes of practice (6; 18%). Fourteen countries (representing approximately two-thirds of grants) progressed at least one stage on the capability maturity model. There were significant increases in all five domains of leadership and organizational capacity (p < 0.01). The number of grants (Kendall's tau = 0.56, p = 0.02), duration of technical assistance (Kendall's tau = 0.50, p = 0.03), and number of learning sessions attended (Kendall's tau = 0.46, p = 0.04) were significantly associated with improvements in in-country collaboration between nursing and midwifery organizations. CONCLUSIONS: The ARC program improved national nursing regulations in participating countries and increased reported leadership, organizational capacity, and collaboration among national nursing and midwifery organizations. These changes help ensure national policies and professional regulations underpin nurse initiated and managed treatment for people living with HIV.

Behavioral Economics: A New Lens for Understanding Genomic Decision Making.

PURPOSE: This article seeks to take the next step in examining the insights that nurses and other healthcare providers can derive from applying behavioral economic concepts to support genomic decision making. As genomic science continues to permeate clinical practice, nurses must continue to adapt practice to meet new challenges. Decisions associated with genomics are often not simple and dichotomous in nature. They can be complex and challenging for all involved. DESIGN: This article offers an introduction to behavioral economics as a possible tool to help support patients', families', and caregivers' decision making related to genomics. METHODS: Using current writings from nursing, ethics, behavioral economic, and other healthcare scholars, we review key concepts of behavioral economics and discuss their relevance to supporting genomic decision making. FINDINGS: Behavioral economic concepts-particularly relativity, deliberation, and choice architecture-are specifically examined as new ways to view the complexities of genomic decision making. Each concept is explored through patient decision making and clinical practice examples. This article also discusses next steps and practice implications for further development of the behavioral economic lens in nursing. CONCLUSIONS: Behavioral economics provides valuable insight into the unique nature of genetic decision-making practices. CLINICAL RELEVANCE: Nurses are often a source of information and support for patients during clinical decision making. This article seeks to offer behavioral economic concepts as a framework for understanding and examining the unique nature of genomic decision making. As genetic and genomic testing become more common in practice, it will continue to grow in importance for nurses to be able to support the autonomous decision making of patients, their families, and caregivers.

Testing Tele-Savvy: Protocol for a randomized controlled trial.

Many informal caregivers of persons with dementia suffer adverse health consequences. Although established psychoeducation programs are known to benefit caregivers, attending in-person programs is challenging for them. To address this challenge, the Savvy Caregiver Program, an evidence-based psychoeducation program with demonstrated effectiveness for caregiving and disease-related outcomes, was transformed into an on-line program, Tele-Savvy. This article describes the rationale for and design of a prospective longitudinal randomized controlled trial (targeted N = 215), currently underway. The trial aims to establish Tele-Savvy's efficacy in (i) reducing the negative effects of caregiving on caregivers; (ii) promoting care recipients' quality of life; (iii) improving caregiver mastery; and to explore (iv) Tele-Savvy's efficacy among caregivers of different races/ethnicities. The mediating role of mastery will be assessed. Participants are randomized to the active condition (immediate Tele-Savvy participation), attention control, or usual care. Participants in the two latter conditions will complete Tele-Savvy 6 months post-baseline. Multilevel mixed effects models will be used to examine changes in outcomes and to model group by time (months since baseline) interactions. The exploratory aim will be addressed using analysis of covariance and qualitative analysis. This trial's results may be used by healthcare and community organizations to implement Tele-Savvy in dementia care, increasing caregivers' access to this evidence-based intervention.

Chronic Stress, Social Isolation, and Perceived Loneliness in Dementia Caregivers.

Caregivers of individuals with dementia are at risk for chronic stress and social isolation. These exogenous factors may lead to perceived stress and perceived loneliness-psychosocial endogenous (subjective) elements of caregiving experience. Chronic stress and perceived loneliness may disrupt neuroendocrine and neuroimmunological regulation, creating low-grade systemic inflammation, promoting proinflammatory gene expression, and expediting cellular aging (endogenous physiological factors). These disturbances may enhance caregivers' risk for chronic conditions of inflammatory pathogenesis. Thus, caregivers' perceived stress and perceived loneliness may form a symptom cluster that can serve as a marker of risks for physical and mental illness. Due to the overwhelming reliance on family caregivers within the increasing population of individuals with dementia, it is essential that clinicians inquire about caregivers' perceived stress and perceived loneliness, are competent in supporting and educating caregivers, and are knowledgeable about specific resources for caregivers. [Journal of Psychosocial Nursing and Mental Health Services, 56(10), 36-43.].

The experience of discrimination by US and Internationally educated nurses in hospital practice in the USA: a qualitative study.

AIM: To document experiences of nurses educated abroad and in the USA in 2 urban hospitals in the southeastern USA. BACKGROUND: Nurses are responsible for providing quality patient care. Discrimination against nurses in the workplace may create hostile environments, potentially affecting patient care and leading to higher nurse attrition rates. Structuration theory posits that agents' interactions create structures. Agents' use of resources and rules shapes interactions, potentially changing the structures. In this study, nurses described interactions with patients and their families and other healthcare personnel, their strategies for managing interactions and rationales behind their selected strategy. DESIGN: This study employed a qualitative, explorative approach using structuration theory. METHODS: In 2011, 42 internationally educated and 40 USA-educated nurses practising in two urban hospitals in the southeastern USA were interviewed about their experiences in the workplace. Forty-one nurses were re-interviewed to explore the issues raised in the preliminary round: 21 internationally educated and 20 USA. Transcripts were analysed using the constant comparative method. FINDINGS: Although internationally educated nurses experienced more explicit discrimination, all nurses experienced discrimination from their patients, their nurse colleagues and/or other hospital personnel. Internationally educated nurses and USA nurses shared similar coping strategies. CONCLUSION: The prevalence of nurses' experiences of discrimination suggests that healthcare institutions need to strengthen policies to effectively address this harmful practice. More research is needed about discrimination against nurses in the workplace because discrimination may have serious psychological effects that impact nurse retention and the quality of patient care.