Advancing the Primary Health Care Mandate for Nursing.

A call to increase home visits and human function documenting by nurses.

Does Social Intelligence Training Improve Daily Well-Being and Responsiveness to Daily Negative and Positive Events in Custodial Grandmothers?

OBJECTIVES: Custodial grandparents are grandparents who raise grandchildren on a full-time basis in absence of the grandchild's birth parents. Compared to noncaregiving grandparents, custodial grandparents report poorer mental and physical health and stronger changes in daily well-being when experiencing negative and positive events. We examine whether an online social intelligence training (SIT) program improves custodial grandmothers' (CGM) daily well-being, socioemotional skills, and changes in well-being when confronted with daily negative and positive events. METHODS: Multilevel models were applied to 200 CGM who were recruited from across the United States and completed a daily survey for 14 consecutive days prior to and following participation in a randomized clinical trial. Participants were randomized into the SIT program or an attention control condition focusing on healthy living habits. The outcomes of interest were daily well-being, social connectedness, emotional awareness, and perspective-taking. RESULTS: Multilevel analyses revealed that participants who participated in the SIT program, compared to the attention control condition, exhibited stronger emotional responsiveness (i.e., improvements) to daily positive events in the outcomes of positive affect, social engagement, and perspective-taking. DISCUSSION: Our findings illustrate that SIT improves key components of daily functioning in CGM, which may serve as a pathway linking the demands of custodial grandparenting to poorer mental and physical health. Our discussion focuses on the utility and accessibility of the SIT program for helping improve outcomes for this disadvantaged population.Clinical Trials Registration Number: NCT03239977.

Assessing Life's Essential 8 and Adverse Childhood Experiences in Grandparent-Grandchild Co-residing Dyads.

We assessed a subset of behavioral indicators from the American Heart Association Life's Essential 8 cardiovascular health (CVH) construct-diet, physical activity, sleep, and nicotine exposure-and quantified associations in scores between members of 12 grandparent-grandchild dyads (grandparents, 52-70 years old; children, 7-12 years old). We also assessed the number of adverse childhood experiences from the dyads. Using the Life's Essential 8 scoring algorithm (0-100, with 100 as optimal), we calculated averages and used Spearman's ρ correlation to quantify associations. Mean score was 67.5 (±12.4) for grandparents and 63.0 (±11.2) for grandchildren. Mean scores for the dyad members were significantly correlated ( r = 0.66, P < .05). The mean numbers of adverse childhood experiences were 7.0 and 5.8 for the grandparents and grandchildren, respectively. The results indicate that CVH in these dyads was suboptimal and interrelated. Adverse childhood experiences in this analysis surpass levels reported as high risk for poor CVH. Our findings suggest that dyadic-based interventions to improve CVH are warranted.

A Randomized Clinical Trial of Online Social Intelligence Training With Custodial Grandmothers.

BACKGROUND AND OBJECTIVES: In this study, we investigated the efficacy of a self-administered, online Social Intelligence Training (SIT) program aimed at enhancing psychological and relational well-being among a nationwide U.S. sample of custodial grandmothers. RESEARCH DESIGN AND METHODS: A two-arm randomized clinical trial (RCT) was conducted, where 349 grandmothers raising grandchildren aged 11-18 years were assigned to either SIT or an attention control condition (ACC). Participants self-completed online surveys at baseline and immediately postintervention, in addition to follow-ups at 3-, 6-, and 9-month postintervention. First-order latent difference score models were used to compare SIT to ACC, across all times of measurement, along key indicators of psychological and relational well-being on an intent-to-treat basis. RESULTS: Although SIT was largely superior to ACC at yielding positive results, it appears that it attenuated longitudinal declines that occurred among ACC participants. SIT also exerted stronger effects on relational than psychological outcomes, with perceived relations with grandchildren being the most positively affected. DISCUSSION AND IMPLICATIONS: Given that the historical time of this RCT unpredictably corresponded with the coronavirus disease 2019 pandemic, we suspect that SIT helped offset declines in psychological and relational well-being that are widely documented to have resulted from the pandemic. Our overall positive findings support future use of the inexpensive and easily delivered SIT program under normal environmental conditions, with the vulnerable and geographically disperse population of custodial grandmothers. CLINICAL TRIALS REGISTRATION NUMBER: NCT03239977.

Efficacy of a Resourcefulness Intervention to Enhance the Physical and Mental Health of Parents Caring for Technology-dependent Children at Home: A Randomized Controlled Trial.

INTRODUCTION: Parent caregivers of children who require lifesaving medical technology (e.g., mechanical ventilation, feeding tubes) must constantly maintain vigilance. Poor physical and psychological health can negatively impact their ability to do so. METHOD: A two-arm randomized controlled trial was conducted with 197 parent caregivers of technology-dependent children (aged < 18 years) to test the efficacy of Resourcefulness Training1, a cognitive-behavioral intervention that teaches social (help-seeking) and personal (self-help) resourcefulness skills, in improving key outcomes including mental health-related quality of life (HRQOL), depressive cognitions and symptoms, perceived and physiological chronic stress, burden, and physical HRQOL at five-time points. RESULTS: Mixed-effects models using the intent-to-treat principle indicated statistically significant improvement with intervention participants at six and/or nine months postintervention for depressive cognitions, perceived stress, and physical HRQOL, controlling for covariates. DISCUSSION: Study findings support the efficacy of Resourcefulness Training to significantly decrease perceived stress and improve psychological/physical outcomes with these vulnerable caregivers.

Intergenerational patterns of attachment in custodial grandfamilies.

The present study aimed to identify intergenerational patterns of attachment insecurity among grandmothers, adolescent grandchildren, and birth mothers in custodial grandfamilies and to test the relations among triadic attachment patterns and grandchild socioemotional outcomes. Prior research with custodial grandfamilies has found distinct "profiles" reflecting patterns of closeness between grandmothers, grandchildren, and birth mothers. However, no studies have tested patterns of attachment insecurity among members of the triad, despite the likelihood of attachment disruption in grandfamilies. Moreover, previous studies have only examined links between profile and grandmother outcomes or rudimentary grandchild outcomes. In a sample of 230 grandmother-grandchild dyads from a larger randomized controlled trial testing the efficacy of an online social intelligence training program for grandfamilies, latent profile analysis (LPA) was conducted to identify profiles of intergenerational attachment insecurity, using grandmother and grandchild reports. Profile differences in grandchild internalizing and externalizing problems, social skills, self-esteem, and prosocial behavior were examined. We identified three profiles: isolated mother, grandchild-linked, and disconnected. Overall, grandchildren in disconnected families (in which attachment insecurity between all three members of the triad was high) fared worst. Grandchildren in isolated mother families (in which only grandmother-grandchild attachment insecurity was low) fared best. A secure attachment relationship between grandmother and adolescent grandchild may buffer effects of attachment insecurity between the grandchild and birth mother. These findings inform intervention efforts and highlight the utility of family- and attachment-focused research for building understanding of custodial grandfamilies. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Self-reported Adverse Childhood Experiences Among Custodial Grandmothers: Frequencies, Patterns, and Correlates.

Given the scarce past research on custodial grandparents' early life circumstances, we investigated frequencies, patterns, and predictors of 14 adverse childhood experiences (ACEs) reported by 355 custodial grandmothers (CGMs). Predominant ACEs were bullying (54.6%), verbal abuse (51.5%), physical abuse (45.4%), and living with a substance abuser (41.1%). Only 11% of CGMs reported 0 ACEs, whereas 52.4% reported >4. Latent class analyses yielded three classes of ACE exposure: minimal (54.1%), physical/emotional abuse (25.9%), and complex (20.0%). Age was the only demographic factor related to ACE class, with the complex class being younger than the other two. MANCOVAs with age as a covariate revealed that different ACE profiles have unique impacts on CGMs' physical and psychological well-being. We conclude that ACEs are highly prevalent among CGMs and a serious public health concern. Future research addressing ACEs among CGMs is critical in order to support these caregivers and promote resilience in custodial grandfamilies.

The Dynamics of Daily Life in Custodial Grandmothers.

OBJECTIVE: Guided by a life-course perspective, we examine the nature of daily life among custodial grandmothers (CGM) through documenting daily positive and negative affect, reporting daily negative and positive events, and emotional reactivity/responsiveness to daily negative and positive events. We also examine whether CGM age, adverse childhood experiences (ACEs), and social relationship quality with grandchild are associated with each indicator. METHODS: We applied multilevel models to 200 CGM (Mage = 61, SD = 5.66) who were recruited from across the United States and completed a daily survey for 14 consecutive days prior to commencing a randomized clinical trial. RESULTS: Older age and reporting fewer ACEs were associated with better overall and less variability in daily well-being. Positive events were reported on 83% of days and negative events were reported on 56% of days. Daily well-being was lower when a negative event was reported and higher when a positive event was reported. Reporting more ACEs was associated with greater exposure to daily negative events and stronger gains in daily well-being when a daily positive event was reported. Older age was associated with lesser declines in daily well-being on days when a negative event was reported. DISCUSSION: In accordance with the life-course perspective, our findings illustrate how the timing of being a CGM (age) and the cumulative nature of development (ACEs) affect daily well-being and negative and positive events for CGM. Our discussion focuses on resources to consider when building resilience-focused interventions for promoting the health and well-being of CGM.

Supporting grandchildren's remote instruction during COVID-19: Experiences of custodial grandmothers.

While negative impacts of COVID-19-related remote instruction on children continue to emerge, it appears that vulnerable students will disproportionately bear the burden. One such vulnerable population is children being raised by grandparents. The purpose of this mixed methods study was to gain insight into custodial grandmothers' (CGMs) experiences of their grandchildren's remote instruction, as well as individual and contextual factors associated with these experiences. A national sample of 315 CGMs, drawn from two randomized clinical trials, completed an online survey in Spring of 2020. Results of a thematic analysis and supplemental quantitative analyses revealed three themes. First, access to technology and instructional supports were critical to the success of remote instruction, with barriers being difficulties using technology and poor-quality remote instruction. Next, grandchild socioemotional difficulties, and fit with remote instruction, were central to their engagement and success with remote instruction. Finally, CGMs experienced multiple stressors related to managing the demands of remote instruction, work, and family. Challenges associated with remote instruction were related to pre-pandemic difficulties such as grandchild problems and CGM depressive symptoms. Collectively, the results highlight how multiple adversities may have amplified grandchildren's existing vulnerability to negative outcomes. Implications are addressed, including strategies for supporting children raised by grandparents beyond the COVID-19 pandemic.

Using a Virtual Platform for Conducting Grandfamily Research.

BACKGROUND: Because of the COVID-19 pandemic, our research team quickly pivoted from planned face-to-face interaction with participants to virtual interactions. During this transition, we discovered invaluable new practices for conducting research remotely, including collecting physiological data. OBJECTIVE: Our objective was to describe the methodological challenges we encountered when conducting this research virtually with grandparent-grandchild dyads and describe the strategies we developed to overcome those challenges. Of primary focus were procedures for finger-stick blood sample collection. Of secondary focus were procedures for conducting virtual-based research with older adults and across multiple generations. METHODS: During an observational study utilizing a virtual platform with 11 grandparent-grandchild dyads (mean age: 64.2 ± 5.0 years for grandparents and 9.3 ± 1.9 years for grandchildren), we documented lessons learned (based on the discussion within our team and feedback we have received from participants) that could be applicable for other, similar research endeavors. RESULTS: We found several challenges in collecting blood samples, including staff were unfamiliar with providing online instruction and participants needed to develop familiarity with the blood sample collection process (without having in-person assistance), and we had to develop methods for delivering blood sample collection kits to participants safely. We also found that it took longer than expected to run procedures-a challenge that might be encountered when conducting any type of dyadic research utilizing a virtual platform-particularly involving older adults and across multiple generations. In addition, it was challenging to keep child participants engaged in the virtual interactions. We document how we employed targeted strategies to overcome those obstacles. Recommendations for strategies from our team include to provide comprehensive and clear instruction/materials on blood sampling procedure, offer generous support throughout the blood collection process, be prepared to divide study visits into more than one session as needed, proactively anticipate potential roadblocks, and carefully consider the participants' developmental stages and attention span. DISCUSSION: The insights we gained will help inform future research with grandparent-grandchild dyads in remote or rural populations utilizing virtual platforms.

Resourcefulness Intervention Efficacy for Parent Caregivers of Technology-Dependent Children: A Randomized Trial.

Parent caregivers of children who require lifesaving technology (e.g., mechanical ventilation, feeding tubes) must maintain a high level of vigilance 24/7. A two-arm randomized controlled trial tested the efficacy of a resourcefulness intervention on parents' mental/physical health and family functioning at four time points over six months. Participants (n = 93) cared for their technology-dependent children <18 years at home. The intervention arm received teaching on social (help-seeking), personal (self-help) resourcefulness skills; access to the intervention video and skill application video-vignettes; four weeks of skills reinforcement using daily logs; four weekly phone contacts; and booster sessions at two- and four-month postenrollment. The attention control arm received phone contact at identical time points plus the current standard of care. Statistically significant improvement was noted; fewer depressive cognitions and improved physical health for the intervention participants than attention control participants over time after controlling for covariates. The findings support the resourcefulness intervention efficacy.

Grandmothers raising grandchildren: managing, balancing and maintaining family relationships.

Most grandparents raising grandchildren are embedded in a network of family members who either help them carry out the caregiving task or complicate that role. This study examined how grandmothers described family relationships, that is, with the grandchild's parents, grandmother's spouses/partners, and other relatives. Data were drawn from 457 weekly journal entries submitted by 129 grandmother caregivers. Using thematic analysis, a three-person team coded using NVIVO 12. Grandmothers described three overarching relationship themes: managing conflicted relationships with the grandchild's parents, balancing relationships with their spouse/partner, and maintaining relationships with other relatives. Implications for practice are provided.

Assessing Cardiometabolic Health Risk Among U.S. Children Living in Grandparent-Headed Households.

PURPOSE: We evaluated children's cardiometabolic health (CMH) risk indicators and adverse childhood experiences (ACEs) stratified by family structure type (grandparent-headed, two-parent headed, and single-parent headed households). Separately, we assessed whether family structure type and number of ACEs were independently associated with the CMH risk indicators. DESIGN AND METHODS: Utilizing data from the 2017-2018 National Survey of Children's Health, we evaluated five CMH risk indicators (obesity, physical activity, secondhand smoke exposure, sleep, and sports participation). We used multivariable logistic regressions to assess the association of CMH risk indicators with family structure type and ACEs. We controlled for sex, age, race/ethnicity, health insurance, household poverty level, and overall health status. RESULTS: Among children aged 10-17 years (n = 24,885), we found the number of ACEs differed by family structure type (P < 0.001) and was independently associated with obesity, secondhand smoke exposure, sleep, and sports participation. Adjusting for all covariates except ACEs, family structure type was significantly associated with children's CMH risk; but after controlling for ACEs that association was attenuated - except for sleep (less adequate sleep in grandparent-headed households) and exposure to secondhand smoke (less exposure in single-parent headed households). CONCLUSIONS: ACEs were highest among children living in grandparent-headed households and independently associated with a majority of the CMH risk indicators. Findings suggest that children living in grandparent-headed households may be at elevated risk for poor CMH, potentially due to higher risk for ACEs. PRACTICE IMPLICATIONS: It is recommended to consider ACEs and family structure type when assessing CMH risk in children.

Successful and Cost-Effective Facebook Recruitment: Is It Possible? Results From a Longitudinal Randomized Clinical Trial in Grandmother Caregivers.

Facebook is often cited in health-related research as a practical option to recruit participants into research studies, but issues with recruiting verifiable and qualified participants and unpredictable costs exist. The purpose of this paper is to describe a social network theory-guided, no-cost, Facebook recruitment strategy in comparison to a traditional recruitment campaign for a national online intervention study for grandmother caregivers (n = 348); 211 participants were recruited via Facebook, and 137 through traditional techniques. Participation rates did not vary by recruitment method. Facebook participants were slightly older, higher income, and more likely to be white and married, but did not differ in education levels. Our strategy quickly obtained an engaged and committed participant base. The application of social network theory to traditional recruitment strategies represents a novel way for researchers to recruit through Facebook and yield viable and engaged participants without investing in Facebook ads.

Theoretical and Operational Consideration of Mindfulness, Resilience, and Resourcefulness.

Mindfulness, resilience, and resourcefulness are theoretically distinct but related constructs critical for improving psychosocial well-being outcomes for informal caregivers and others. Our aims were to evaluate the theoretical and operational distinctions among these constructs. Measures of mindfulness (Decentering Scale), resilience (Connor-Davidson Scale) and resourcefulness (Resourcefulness Scale) were collected from a national sample of 348 grandmother caregivers. We conducted exploratory factor analysis and examined correlation patterns. Inter-correlations ranged from r= .26 (resourcefulness and resilience) to r= .73 (resilience and mindfulness). Factor analyses and scree plots indicated unidimensional factors for resilience and for mindfulness, and two factors for resourcefulness (personal and social). When items from all measures were analyzed together, the four factors remained. Distinct relationships were found between mindfulness, resilience, and resourcefulness with relevant external variables. Our results support the conceptual distinctions among the constructs, providing support for interventions targeting these constructs to improve psychosocial outcomes in caregivers.

Assessing Access to Five Types of Insurance by People with Multiple Sclerosis Using a Cross-sectional Online Survey.

BACKGROUND: Many individuals with multiple sclerosis (MS) depart the workforce prematurely. In the United States, access to insurance, including health, disability income, long-term care, and life insurance, is largely employment-based or purchased from earnings. Many individuals we see in the clinic experience financial hardship because of a lack of insurance, even if working. We sought to determine the proportion of workers who are financially protected through insurance coverage and the sources of this coverage in a large sample. METHODS: We developed an online survey and opened it to individuals aged 18 to 65 years registered with the North American Research Committee on Multiple Sclerosis, iConquerMS, or the National Multiple Sclerosis Society Minority Advisory Council. Data collected included demographic and disease characteristics, current information about each insurance type (coverage vs no coverage), and when the current insurance policies were obtained relative to MS diagnosis. RESULTS: Of 2507 survey respondents, 82.9% were female, 3.8% Hispanic/Latino, and 91.2% White. The mean ± SD age was 53.5 ± 8.5 years and disease duration was 16.4 ± 8.5 years after diagnosis. The most frequently held insurance types were health (96.3%) and life (58.8%). Only 9.7% of respondents had long-term care insurance. Except for life insurance, most current policies were obtained after MS diagnosis. CONCLUSIONS: Individuals with MS might not prioritize the possible short- and long-term benefits of these types of insurance. Health care providers can direct patients to nonprofit agencies that educate about of these insurance types and emphasize that others with MS have obtained these insurance types after their diagnosis.

Incidental findings: A practical protocol for reporting elevated depressive symptoms in behavioral health research.

Intervention studies conducted in caregivers often focus on improving mental health. Consequently, researchers may discover incidental findings like elevated depressive symptoms. Researchers have an ethical obligation to report incidental findings to participants, but no protocols exist for reporting behavioral health symptoms. The purpose of this paper was to describe a protocol for reporting elevated depressive symptoms to participants, based on the protocol used in a national randomized clinical trial of stress-reduction methods for 348 grandmothers raising grandchildren. Each questionnaire included the CES-D scale, and was scored immediately after completion. We established a cut-off score of 30 based on previous research. A registered nurse on the research team called participants with scores over 30 and ascertained whether the participant 1) was aware of the problem and 2) had sought help, and then offered additional resources. Overall, 94 (27%) participants had a CES-D score > 30. The majority (91%) were aware of the problem. About a third of the participants were on medication for their symptoms, and a third were seeing a therapist. Nine participants were not aware they had depressive symptoms. This paper outlines the ethical premise for developing our protocol, details of protocol development, and discussion for how research teams can apply this protocol to their work.

Doctor of nursing practice (DNP) degree in the United States: Reflecting, readjusting, and getting back on track.

BACKGROUND: In 2004, the American Association of Colleges of Nursing (AACN) called for all nursing schools to phase out master's-level preparation for advanced practice registered nurses (APRNs) and transition to doctor of nursing practice (DNP) preparation only by 2015. Today, five years after the AACN's deadline, nursing has not yet adopted a universal DNP standard for APRN practice entry. PURPOSE: The purpose of this paper is to examine the factors influencing the ability of nursing schools to implement a universal DNP standard for APRNs. METHODS: Deans from top-ranked nursing schools explore the current state of the DNP degree in the US. The authors draw upon their collective experience as national leaders in academic nursing, long-time influencers on this debate, and heads of DNP programs themselves. This insight is combined with a synthesis of the literature and analysis of previously unpublished data from the AACN on trends in nursing doctoral education. FINDINGS: This paper highlights issues such as the long history of inconsistency (in messaging, curricula, etc.) surrounding the DNP, certification and accreditation challenges, cost barriers, and more. The authors apply COVID-19 as a case study to help place DNP graduates within a real-world context for health system stakeholders whose buy-in is essential for the success of this professional transition. DISCUSSION: This paper describes the DNP's standing in today's professional environment and advances the conversation on key barriers to its adoption. Insights are shared regarding critical next steps to ensure national acceptance of the DNP as nursing's terminal practice degree.

Building a Research Data Repository for Chronic Condition Self-Management Using Harmonized Data.

BACKGROUND: Building nursing research data repositories with the goal of comparing and synthesizing results across numerous studies and public sharing of data is still in early stages of development. OBJECTIVES: We describe the process of using common data elements (CDEs) to build a data repository for research addressing self-management of chronic conditions. Issues in the development of CDEs, lessons learned in the creation of a combined data set across seven studies of different chronic condition populations, and recommendations for creating and sharing harmonized nursing research data sets are provided. METHODS: In 2014, at initiation of a National Institutes of Health-funded Centers of Excellence in Self-Management Research, our center investigators defined a set of CDEs for use in future center-funded pilot studies consisting of populations having different chronic conditions with the intent to combine the study data sets. Over the next 4 years, center investigators were provided with standardized codebooks and data collection protocols for applying the CDEs and data storage. Data from seven pilot studies were subsequently combined. RESULTS: Although each pilot study was small-with sample sizes ranging from 18 to 31 participants-our combined data set of 179 participants provides us with a sample size sufficient to conduct analyses that could not be done with the individual small samples alone. The research data repository addressing self-management of chronic conditions will soon be available for public sharing. DISCUSSION: Our experience demonstrates that, with careful, upfront planning and ongoing vigilant oversight, CDEs can be applied across studies consisting of different chronic condition populations to combine data sets to create research data repositories for public sharing.