"It Is OK Not to Be OK": Nursing Students' Backgrounds and Perceptions of Mental Health Stigma and Implications for Mental Health Nursing Education.

There has been a notable increase in reported mental illnesses in recent years. Although mental illness is being discussed more openly, stigma toward mental illness still exists. Stigma can result in inadequate care for people with mental illnesses. Students come into nursing from a variety of backgrounds and these backgrounds influence their nursing clinical judgments, especially related to caring for people with mental illnesses. A qualitative descriptive analysis was conducted using 60 undergraduate nursing student reflections on their backgrounds and perceptions of mental health stigma. Students wrote about their Previously Held Beliefs and the Influence of Culture, Overcoming Stigma through their Experiences with Friends and Family, Influence of Popular Culture, and Personal Experiences, and their New Understanding of mental illness and what that means for their future nursing practice. These findings have important implications for nursing education including providing more opportunities for nursing students to care for people with mental illnesses, reframing how mental health content is delivered in undergraduate nursing programs, and providing additional support for students with personal mental illnesses.

Staff and Proxy Views of Multiple Family Member Involvement in Decision Making for Nursing Home Residents With Advanced Dementia.

Decision making for nursing home (NH) residents with Alzheimer disease and related dementias often involves input from multiple family members and NH staff to address goals of care at the end of life. Using data from the Assessment of Disparities and Variation for Alzheimer's disease Nursing home Care at End of life research study, a secondary analysis of qualitative data was conducted involving interviews of 144 NH staff and 44 proxies in 14 NHs to examine the perspectives of NH staff and proxies for NH residents with Alzheimer disease and related dementias on the involvement of multiple family members in decision making about end-of-life care decisions. Interviews took place between 2018 and 2021. Nursing home staff and proxies had differing perspectives of the involvement of multiple family members in decision making, with NH staff primarily viewing families as a source of conflict, whereas proxies viewed families as a source of support. Nursing home staff also had differing opinions of their role with families; some attempted to ameliorate conflict, and some did not get involved. Some NH staff felt that Black families had more conflict than White families, indicating unacceptable bias and stereotyping of Black families by NH staff. These findings suggest training and education is needed for NH staff to facilitate better communication with families and to support proxies in end-of-life decision making to address goals of care for NH residents with Alzheimer disease and related dementias.

Black and white proxy experiences and perceptions that influence advanced dementia care in nursing homes: The ADVANCE study.

BACKGROUND: Regional, facility, and racial variability in intensity of care provided to nursing home (NH) residents with advanced dementia is poorly understood. MATERIALS AND METHODS: Assessment of Disparities and Variation for Alzheimer's disease NH Care at End of life (ADVANCE) is a multisite qualitative study of 14 NHs from four hospital referral regions providing varied intensity of advanced dementia care based on tube-feeding and hospital transfer rates. This report explored the perceptions and experiences of Black and White proxies (N = 44) of residents with advanced dementia to elucidate factors driving these variations. Framework analyses revealed themes and subthemes within the following a priori domains: understanding of advanced dementia and care decisions, preferences related to end-of-life care, advance care planning, decision-making about managing feeding problems and acute illness, communication and trust in NH providers, support, and spirituality in decision-making. Matrix analyses explored similarities/differences by proxy race. Data were collected from June 1, 2018 to July 31, 2021. RESULTS: Among 44 proxies interviewed, 19 (43.1%) were Black, 36 (81.8%) were female, and 26 (59.0%) were adult children of residents. In facilities with the lowest intensity of care, Black and White proxies consistently reported having had previous conversations with residents about wishes for end-of-life care and generally better communication with providers. Black proxies held numerous misconceptions about the clinical course of advanced dementia and effectiveness of treatment options, notably tube-feeding and cardiopulmonary resuscitation. Black and White proxies described mistrust of NH staff but did so towards different staffing roles. Religious and spiritual beliefs commonly thought to underlie preferences for more intense care among Black residents, were rarely, but equally mentioned by race. CONCLUSIONS: This report refuted commonly held assumptions about religiosity and spirituality as drivers of racial variations in advanced dementia care and revealed several actionable facility-level factors, which may help reduce these variations.

ADVANCE-C: A Qualitative Study of Experiences Caring for Nursing Home Residents with Advanced Dementia During the COVID-19 Pandemic.

OBJECTIVES: Assessment of Disparities and Variation for Alzheimer's disease Nursing home Care at End of life (ADVANCE) is a multisite qualitative study of regionally diverse Nursing homes (NHs; N = 14) providing varied intensity of advanced dementia care. ADVANCE-C explored the experiences of NH staff and proxies during the COVID-19 pandemic. METHODS: Data collection occurred in five of the ADVANCE facilities located in Georgia (N = 3) and New York (N = 2). Semistructured qualitative interviews with NH staff (N = 38) and proxies of advanced dementia residents (N = 7) were conducted. Framework analyses explored five staff domains: care processes, decision making, organizational resources, vaccinations, and personal experience, and five proxy domains: connecting with residents, NH response, communicating with NH, decision making, and personal impact of the pandemic. RESULTS: Staff mentioned difficulties implementing infection control policies specifically for advanced dementia residents. Staff reported trust between the facility and proxies as critical in making decisions during the pandemic. All staff participants spoke about "coming together" to address persistent staffing shortages. Proxies described their role as an "emotional rollercoaster," emphasizing how hard it was being separate from their loved ones. The accommodations made for NH residents were not beneficial for those with advanced dementia. The majority of proxies felt NH staff were doing their best and expressed deep appreciation for their care. DISCUSSION: Caring for advanced dementia residents during the COVID-19 pandemic had unique challenges for both staff and proxies. Strategies for similar future crises should strive to balance best practices to contain the virus while maintaining family connections and person-centered care.

Nursing Home Staff Perceptions of End-of-Life Care for Residents With Advanced Dementia: A Multisite Qualitative Study.

Nursing homes (NHs) are an important site of death for residents with advanced dementia. Few studies have explored the experiences of NH staff about providing end-of-life care for residents with advanced dementia. This study aimed to describe NH staff perceptions on where end-of-life care should be delivered, the role of Medicare hospice care, and their experiences providing end-of-life care to residents with advanced dementia. Data from the Assessment of Disparities and Variation for Alzheimer's disease Nursing home Care at End of life study were used to explore the study objectives. Semistructured interviews with 158 NH staff working in 13 NHs across the United States were analyzed. Most NH staff endorsed the NH as a better site of death for residents with advanced dementia compared with a hospital. They expressed mixed perceptions about hospice care. However, regardless of their role, the staff expressed experiencing difficult emotions while providing end-of-life care to residents with dementia because of the close attachments they had formed with them and bearing witness to their decline. The findings show that most NH staff have strong emotional attachments to their dying residents with dementia and prefer to care for them at the NH rather than transfer them to the hospital.

Guilt as an Influencer in End-of-Life Care Decisions for Nursing Home Residents With Advanced Dementia.

The concept of guilt has been studied in the context of caregivers of older adults with advanced dementia, usually describing the feelings a person has of placing a loved one in a long-term care facility; however, little research has been done to understand how nursing home staff and proxies for older adults with dementia describe guilt as a decision-influencer in end-of-life care. For the current study, private, semi-structured interviews were conducted with 158 nursing home staff and 44 proxies in 13 nursing homes across four demographic regions in the United States. Interviews were reviewed and analyzed for how the concept of guilt was perceived as a decision-influencer. Nursing home staff described guilt as an important influencer in why proxies make decisions about end-of-life care. Staff noted that proxies who felt guilty about their relationship with their loved one or lack of time spent at end-of-life tended to be more aggressive in care decisions, whereas no proxies mentioned guilt as an influencer in care decisions. Rather, proxies used language of obligation and commitment to describe why they make decisions. Findings highlight the disconnect between nursing home staff and proxies in what motivates proxies to make end-of-life decisions for loved ones. Nursing home staff should be aware of misconceptions about proxies and work to understand proxies' true rationale and motivations for making care decisions. [Journal of Gerontological Nursing, 48(1), 22-27.].

Association of Nursing Home Organizational Culture and Staff Perspectives With Variability in Advanced Dementia Care: The ADVANCE Study.

IMPORTANCE: Regional, facility, and racial and ethnic variability in intensity of care provided to nursing home residents with advanced dementia is well documented but poorly understood. OBJECTIVE: To assess the factors associated with facility and regional variation in the intensity of care for nursing home residents with advanced dementia. DESIGN, SETTING, AND PARTICIPANTS: In the ADVANCE (Assessment of Disparities and Variation for Alzheimer Disease Nursing Home Care at End of Life) qualitative study, conducted from June 1, 2018, to July 31, 2021, nationwide 2016-2017 Medicare Minimum Data Set information identified 4 hospital referral regions (HRRs) with high (n = 2) and low (n = 2) intensity of care for patients with advanced dementia based on hospital transfer and tube-feeding rates. Within those HRRs, 14 facilities providing relatively high-intensity and low-intensity care were recruited. A total of 169 nursing home staff members were interviewed, including administrators, directors of nursing, nurses, certified nursing assistants, social workers, occupational therapists, speech-language pathologists, dieticians, medical clinicians, and chaplains. MAIN OUTCOMES AND MEASURES: Data included 275 hours of observation, 169 staff interviews, and abstraction of public nursing home material (eg, websites). Framework analyses explored organizational factors and staff perceptions across HRRs and nursing homes in the following 4 domains: physical environment, care processes, decision-making processes, and implicit and explicit values. RESULTS: Among 169 staff members interviewed, 153 (90.5%) were women, the mean (SD) age was 47.6 (4.7) years, and 54 (32.0%) were Black. Tube-feeding rates ranged from 0% in 5 low-intensity facilities to 44.3% in 1 high-intensity facility, and hospital transfer rates ranged from 0 transfers per resident-year in 2 low-intensity facilities to 1.6 transfers per resident-year in 1 high-intensity facility. The proportion of Black residents in facilities ranged from 2.9% in 1 low-intensity facility to 71.6% in 1 high-intensity facility, and the proportion of Medicaid recipients ranged from 45.3% in 1 low-intensity facility to 81.3% in 1 high-intensity facility. Factors distinguishing facilities providing the lowest-intensity care from those providing the highest-intensity care facilities included more pleasant physical environment (eg, good repair and nonmalodorous), standardized advance care planning, greater staff engagement in shared decision-making, and staff implicit values unfavorable to tube feeding. Many staff perceptions were ubiquitous (eg, adequate staffing needs), with no distinct pattern across nursing homes or HRRs. Staff in all nursing homes expressed assumptions that proxies for Black residents were reluctant to engage in advance care planning and favored more aggressive care. Except in nursing homes providing the lowest-intensity care, many staff believed that feeding tubes prolonged life and had other clinical benefits. CONCLUSIONS AND RELEVANCE: This study found that variability in the care of patients with advanced dementia may be reduced by addressing modifiable nursing home factors, including enhancing support for low-resource facilities, standardizing advance care planning, and educating staff about evidence-based care and shared decision-making. Given pervasive staff biases toward proxies of Black residents, achieving health equity for nursing home residents with advanced dementia must be the goal behind all efforts aimed at reducing disparities in their care.

Trust of Nursing Home Staff Caring for Residents with Advanced Dementia: A Qualitative Descriptive Study of Family Caregivers' Perspectives.

BACKGROUND/OBJECTIVES: Studies of interpersonal trust within nursing homes (NHs) is limited. This study aimed to describe the perspectives of interpersonal trust in NH staff among family caregivers of residents with advanced dementia. Additionally, comparisons of Black and White caregivers' perspectives were also explored. DESIGN: We used data generated from a parent study, Assessment of Disparities and Variation for Alzheimer's disease Nursing home Care at End of life (ADVANCE) to examine the experience of trust from the family caregivers' perspectives. PARTICIPANTS: Data generated from interviews with 44 family caregivers of residents with advanced dementia (Black n = 19 and White n = 25) were analyzed using thematic analysis. RESULTS/CONCLUSIONS: While both Black and White family caregivers experienced trust and mistrust, Black caregivers more often experienced differential mistrust. As differential mistrust is a new concept relative to trust, additional research is required to elucidate its meaning. DESIGN: We used data generated from a parent study, Assessment of Disparities and Variation for Alzheimer's disease Nursing home Care at End of life (ADVANCE) to examine the experience of trust from the family caregivers' perspectives. PARTICIPANTS: Data generated from interviews with 44 family caregivers of residents with advanced dementia (Black n = 19 and White n = 25) were analyzed using thematic analysis. RESULTS/CONCLUSIONS: While both Black and White family caregivers experienced trust and mistrust, Black caregivers more often experienced differential mistrust, trust for certain staff members and mistrust of others. As differential mistrust is a new concept relative to trust, additional research is required to elucidate its meaning.

An Innovative Concept-Based Learning Activity to Identify and Educate Veterans at Risk for Amputation.

ABSTRACT: Nurse educators must create meaningful learning for students while addressing the needs of a rapidly changing health care system. Academic-practice partnerships help ensure that students are up-to-date on current practices while faculty and students partner to support the needs of the practice institution. To address a health care system's high amputation rates, school of nursing faculty developed a concept-based learning activity to assess and educate patients at risk for amputation. Results included increased student learning that can be applied to other practice settings and improved outcomes for the health care system.

Kids helping kids: The lived experience of adolescents who support friends with mental health needs.

PROBLEM: Adolescent mental health is a significant health care issue. Friends play an important role in the lives of adolescents with mental health concerns and help to improve outcomes related to depression and suicide. However, little is known about the experiences of adolescents who help their friends with these concerns. METHODS: A phenomenological research design involving unstructured interviews was used to answer the question: what is the lived experience of adolescents who provide support to friends with anxiety, depression, or who express suicidal ideation?" Participants for this study were aged 16-17 and included both males (n = 2) and females (n = 3). FINDINGS: Participants described their experience as "Kids Helping Kids" which is defined by the following themes: Being Fearful, Maintaining Vigilance, Seeking Knowledge, Keeping Secrets, Involving Others, Setting Boundaries, and Feeling Honored. CONCLUSION: Helping a friend with mental health concerns can be challenging yet rewarding. Nurses should be aware of this role that some adolescents undertake and include the friends of adolescents with mental health concerns as part of plans of care.

I don't have the choice to burnout; experiences of parents of children with type 1 diabetes.

AIM: The purpose of the study was to explore the description of diabetes burnout in parents of children with type 1 diabetes (T1D). BACKGROUND: Parents of children with T1D struggle to balance diabetes management and typical parenting challenges, which may lead to diabetes burnout. Although diabetes burnout is a familiar concept in public forum and diabetes literature, science on diabetes burnout in parents is lacking. METHODS: In this qualitative descriptive study, a systematic approach was used to search existing relevant YouTube videos about diabetes burnout produced by parents of children with T1D. Verbatim transcripts of 21 videos meeting inclusion criteria were analyzed using a qualitative content analysis approach. To summarize video characteristics, descriptive statistics were used. RESULTS: It identifies four primary themes related to diabetes burnout in this population: "exhaustion compounded by stress," "powerlessness to control diabetes," "grief for the loss of a normal life," and "coping strategies." CONCLUSION: The findings of this study may serve to clarify how parents of children with T1D may experience diabetes burnout. The findings may also inform diabetes care and illuminate the role of social media in improving family center support.

Veteran-Centric Content Integration Into a Baccalaureate Nursing Curriculum.

BACKGROUND: Nurse educators frequently search for innovative ways to address specific population needs such as those presented by veterans. METHOD: To integrate veteran-centric content into undergraduate nursing curriculum, Veterans Affairs Nursing Academic Partnership (VANAP) faculty conducted a literature review, collaborated with stakeholders, developed veteran-centric competencies, identified natural areas in existing curriculum for content integration, developed learning activities, and created a content integration map. RESULTS: Eight VANAP competencies were developed to guide content integration. A map of veteran-centric content integration into the baccalaureate curriculum was created, and content was integrated into theory and clinical courses, and simulation experiences in the undergraduate program. CONCLUSION: The strategies for incorporating veteran-centric care into a curriculum can be used by all nurse educators to integrate and maintain various population-specific content. [J Nurs Educ. 2020;59(7):400-404.].

A concept analysis of adolescent friendship.

AIM: The purpose of this study is to provide a definition of adolescent friendship to aid in nursing research and practice. BACKGROUND: Friendships are an essential part of adolescence and can have significant impacts on health outcomes. Adolescent friendships are associated with decreased depression, suicidal ideation, anxiety, and improved self-management of chronic conditions. However, the concept of friendship has not been well defined in the nursing literature, especially in the context of adolescents. DESIGN: Walker and Avant's method of concept analysis was used as a framework for this analysis. DATA SOURCES: Seventeen articles were reviewed, representing a variety of disciplines including child development, psychology, sociology, behavioral sciences, medicine, education, public health, and nutrition. Additional sources included online definitions of friendship. REVIEW METHODS: After reviewing the sources, the author identified attributes, antecedents, and consequences. Model case, a borderline case, and contrary case were developed and empirical referents identified. RESULTS: The analysis resulted in a clear definition of adolescent friendship, containing the attributes of support, intimacy, affection, trust, ability to manage conflict, and time. CONCLUSIONS: Understanding the attributes, antecedents, and consequences of adolescent friendships will help nurses in assessing and supporting these influential relationships during this important development period.

Incorporating Group Interviews Into Holistic Review in Baccalaureate Nursing School Admissions.

Holistic review in admissions considers an applicant's background and experience in combination with academic achievement. In order to evaluate baccalaureate nursing school applicants more holistically, a school of nursing added group interviews as part of the admissions process. The school's Admission and Progression Committee consulted with other schools, developed interview questions, and implemented a strategy to interview applicants. Results of this process were high levels of candidate and faculty satisfaction and enrollment of a diverse cohort of students with a high preadmission grade point average. Areas for improvement and further research are discussed.

An Academic-Practice Partnership: Fostering Collaboration and Improving Care Across Settings.

BACKGROUND: Through the Veterans Affairs Nursing Academic Partnership (VANAP), baccalaureate nursing students and faculty participated in practice innovations in a Veterans Affairs Health Care System. Nationally, VANAP has attempted to bridge gaps between theory and practice and across care settings. APPROACH: In a population health course, nursing students were placed in both inpatient and outpatient settings. Through activities such as postconferences and population-based projects, students joined forces with Veterans Affairs staff on issues that affected veterans' health care. OUTCOMES: Two student groups worked on amputation prevention from opposite ends of the spectrum. Their projects, with the continuation of these by faculty and staff, resulted in 47% decrease in vascular-related hospital readmissions. CONCLUSIONS: Student placements in settings across the care continuum improved communication between the settings. The enhanced partnership between the 2 organizations addressed a relevant, meaningful patient care issue.

Supportive Peer Relationships and Mental Health in Adolescence: An Integrative Review.

In the United States, nearly one in five adolescents has a diagnosable mental health disorder. Beginning in the teenage years, adolescents become less reliant on their parents for support and begin to turn to their peer group for support; therefore, it is important to understand the role of peers during this developmental time, especially in relation to mental health. The purpose of this project is to review the literature regarding positive peer support and mental health in adolescence. CINAHL, PubMed, and PsycINFO were used to conduct the review. The inclusive years of the search were 2007-2017. A total of 15 studies were included for review. The results were consistent over time and settings, demonstrating the positive role of peer support in adolescences with mental health care needs. Following a synthesis of the literature, gaps in research and implications for practice and further research, are discussed.