Stigma and Spiritual Well-being among People Living with HIV/AIDS in Southern Appalachia.

The Appalachian South is disproportionately affected by HIV/AIDS. Partly due to the negative connotation that this disease carries in religiously conservative areas, HIV-related stigma remains a critical barrier to HIV care in the South. However, spirituality is a well-documented, effective coping mechanism among persons living with HIV/AIDS (PLWH). The purpose of this study was to examine the relationship between HIV-related stigma and spiritual well-being among a sample of PLWH (n = 216) in Appalachian counties of Tennessee and Alabama using the HIV Stigma Scale and the Spiritual Well-being Scale. Overall, disclosure of HIV status was the most highly reported stigma concern. Women reported higher levels of stigma and religious well-being than men. While existential well-being was negatively correlated with stigma, no significant overall correlation was found between religious well-being and stigma. Our findings reveal the importance of defining theology and differentiating between cultural religious conditioning and internalized beliefs.

Girlhood Betrayals of Women Childhood Trauma Survivors in Treatment for Addiction.

PURPOSE: This research explored the understanding of trauma from the perspective of women who had experienced abuse and neglect in childhood. The goal was to better conceptualize potential avenues or interventions for prevention and treatment. DESIGN: Qualitative description of the accounts of eight women who were childhood trauma survivors and in treatment for addiction. Open-ended interviews focused on key events or experiences during childhood and adolescence and the use of drugs and alcohol. FINDINGS: Four levels of betrayal fit the accounts the participants gave as the dominant theme in their narratives. "Primary betrayal" referred to the direct victimization by a perpetrator; "secondary betrayal" referred to the complicity, denial, or indifference of another adult to the child's victimization; "tertiary betrayal" referred to failures of responsible individuals in community settings to protect the child; and "quaternary betrayal" represented self-betrayals. Substance misuse was an adolescent self-betrayal that provided initial solace yet ultimately threatened the integrity of the girls. We found an almost complete lack of support in family and community settings for the participants. CONCLUSIONS: These findings on betrayal inform health care for trauma survivors and can be a framework for preventing violence against children. CLINICAL RELEVANCE: Interventions for child and adolescent trauma survivors are critical to prevent the life-long health sequelae of childhood trauma. Pivotal times to engage these survivors include periods when they may be accessed in school and healthcare settings.

Continuing the conversation in nursing on race and racism.

Nursing values include diversity and a commitment to the elimination of health disparities. However, nursing comprises predominantly white, female nurses. The authors explore structural and interpersonal sources of disparities experienced by black persons, including white privilege. Here, the authors advocate for a continuation of the racism conversation, specifically among white nurses. Racial disadvantages stem from structural inequalities from daily slights, and usually unintended subtle racism toward black people on the part of white people, including white nurses. By raising consciousness on how we propagate subtle racism, nursing can progress faster in eliminating health disparities. Topics include postracialism, colorblindness, institutional racism, white privilege, health disparities, clinical encounters, subtle racism, and racial microaggressions. Suggestions for open dialogue, historical awareness, education, research, and practice are highlighted. Difficulties involved in confronting racism and white privilege are explored.

Anger in the trajectory of healing from childhood maltreatment.

When a girl is abused during childhood, she may not experience anger, only helplessness or numbness. Only later may the emotion of anger surface. Little is known about anger cognitions or behaviors as they occur across the years of the healing trajectory from childhood maltreatment. Data for the present secondary analysis were derived from a large narrative study of women thriving in adulthood despite childhood abuse. The purpose of this analysis was to examine the phenomenon of anger and its role in the recovery process of 6 midlife women. The 6 cases were purposefully selected because their interviews contained rich descriptions of anger experiences. Because each woman was interviewed 3 times over a 6- to 12-month period, 18 transcripts were available for in-depth examination. A typology was constructed, depicting 5 types of anger. Anger ranged from nonproductive, self-castigating behavior to empowering, righteous anger that enabled women to protect themselves from further abuse and to advocate for abused children. Study findings are relevant to extant theories of women's anger and feminist therapies.

Narrative methods in a study of trauma recovery.

Multiple narrative perspectives can guide narrative research. The complexity of health narratives presents a significant challenge. Trauma recovery accounts are health narratives demonstrating successes as well as struggles. In this article, I describe a large-scale narrative study in which specific qualitative methods were combined to fit research aims, stories elicited, and emergent questions in the analysis process. Under my direction, an interdisciplinary team conducted this constructivist, feminist, narrative study describing the trauma recovery process. The study was focused on success or thriving in women surviving childhood maltreatment. I took an advocacy stance in favor of participants' interests, as is commensurate with a critical feminist standpoint. Through initial analyses the research team constructed a trauma recovery process termed "becoming resolute." Subanalyses were focused on key relationships, life trajectories, self-strategies, and perceptual changes. My purpose is to explain the various kinds and levels of analysis used here to provide options for others studying recovery narratives.

"I knew it was wrong the moment I got the order": A narrative thematic analysis of moral injury in combat veterans.

OBJECTIVE: Moral injury is a nascent construct intended to capture reactions to events that violate deeply held beliefs and moral values. Although a model of moral injury has been proposed, many of the theoretical propositions of this model have yet to be systematically studied. METHOD: We conducted semistructured interviews with eight veterans who reported experiencing morally injurious events during war zone deployments. RESULTS: Using narrative thematic analysis, five main themes and associated subthemes emerged from the data. The main themes capture the timing of the event, contextual factors that affected the decision-making process during the morally injurious event, reactions to the moral injurious event, search for purpose and meaning, and opening up. CONCLUSION: The findings from the present study supported an existing model of moral injury, while extending it in several important ways. Preliminary clinical recommendations and directions for future research are discussed based on the study findings. These include directly exploring the context surrounding the morally injurious event, examining the veterans' moral appraisals, and helping them assume appropriate responsibility for their actions to reduce excessive self-blame. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Life trajectories of female child abuse survivors thriving in adulthood.

A narrative study of thriving adult female survivors of childhood maltreatment was undertaken to discover how they had achieved success. Life trajectory patterns, turning points, and setbacks were identified. Data consisted of 81 interview transcripts derived from a series of three interviews, spaced over 6 to 12 months, with 27 survivors. The childhood abuse was intrafamilial, beginning as early as infancy and continuing, in most cases, until participants left home. The onset and pace of the healing trajectory were quite variable, including a roller-coaster pattern as well as patterns of slow, steady progress and continued struggle. Four types of redemption narratives were delineated. Survivors had not been spared depression but had made achievements in work and education and displayed remarkable generativity, parenting their own children well, and mentoring other young girls, especially victims of abuse.

Tomboys: meanings, marginalization, and misunderstandings.

Girls who act like boys are called "tomboys." This is an exploration using feminist guiding principles, about what "tomboyism" means to children and how adults around them construct it. The purpose is to examine tomboyism from literary, linguistic, historical and cultural perspectives. The exploration includes a review of selected scientific sources, children's and some adult literature, and conversations with adult women who recall their tomboyism from youth and how it now affects them as adults.

Marginalization: A Revisitation With Integration of Scholarship on Globalization, Intersectionality, Privilege, Microaggressions, and Implicit Biases.

In 1994, the concept of marginalization was explored in an article in Advances in Nursing Science. This is a revisitation of the concept incorporating new scholarship. This update is founded on feminism, postcolonialism, critical race theory, and discourse deconstruction, all viewpoints that have been explicated in nursing. The purpose of this analysis is to look at new scholarship and concepts useful to applying marginalization in nursing knowledge development from the standpoint of Bourdieu's macro, meso, and micro levels. New scholarship includes globalization, intersectionality, privilege, microaggressions, and implicit bias. Implications for decreasing health disparities through this new scholarship are discussed.

The Marijuana Phenomenon: Contradictions and Silence.

The United States is trending toward more permissiveness regarding recreational and medicinal marijuana (MJ). Many conditions for which MJ is recommended, prescribed, or self-prescribed are symptoms that advanced practice nurses address daily. Yet, the silence of nursing scientists on ethics, practices, and policies regarding such clinical decisions is deafening. This is but one of many contradictions about MJ use that we discuss in this article. We do not propose to resolve these contradictions; that is left to the community of nurse scientists in interprofessional discourse. Collectively, we must explore these contradictions and, through evidence-based policy recommendations, overcome the silence about how providers view MJ, how it might be helpful, its risks, and cultural shifts that have accompanied a changed political/legal environment. Long term, we must close the gaps in the nursing knowledge base regarding MJ as it affects users and how it is used interventionally.

"It's Killing Us!" Narratives of Black Adults About Microaggression Experiences and Related Health Stress.

Perceived racism contributes to persistent health stress leading to health disparities. African American/Black persons (BPs) believe subtle, rather than overt, interpersonal racism is increasing. Sue and colleagues describe interpersonal racism as racial microaggressions: "routine" marginalizing indignities by White persons (WPs) toward BPs that contribute to health stress. In this narrative, exploratory study, Black adults (n = 10) were asked about specific racial microaggressions; they all experienced multiple types. Categorical and narrative analysis captured interpretations, strategies, and health stress attributions. Six iconic narratives contextualized health stress responses. Diverse mental and physical symptoms were attributed to racial microaggressions. Few strategies in response had positive outcomes. Future research includes development of coping strategies for BPs in these interactions, exploration of WPs awareness of their behaviors, and preventing racial microaggressions in health encounters that exacerbate health disparities.

Survivor guilt: analyzing the concept and its contexts.

Survivor guilt, a concept associated with the interpersonal process of "surviving" harm while others do not, increasingly appears in nursing, medicine, and psychology literature. Paradoxically, the phenomenon is rarely defined and often poorly described. Combining Rodger's evolutionary concept analysis with a comprehensive literature review, we explain the attributes, antecedents, consequences, related concepts, and surrogate terms of survivor guilt. A new definition emerged from the evolving use of the concept in new contexts. Survivor guilt is a valid form of suffering for which effective interventions need to be developed. This analysis extends the concept, laying the foundation for comprehensive treatment strategies.

Dissociative experiences of women child abuse survivors: a selective constructivist review.

A selective literature review of dissociation in women abuse survivors was under-taken from a feminist, constructivist perspective. Dissociation has been conceptualized many ways historically. Current understandings of dissociative phenomena are diverse, as reflected in the research and treatment literature. Dissociation has been linked to physical and psychological problems, including major mental illnesses, pelvic pain, somatization disorders, and eating disorders. There has been a preoccupation with rare but fascinating extremes of dissociation, such as multiple personality disorder, with less emphasis on more frequently seen types of dissociation, such as depersonalization and derealization. Views of dissociation as it occurs in women child abuse survivors affect their autonomy and perceived credibility and determine treatment trajectories. Questions remain as to what aspects and types of dissociation are "pathological." There is evidence that dissociation may be a commonplace human experience in the general population. Implications for theory, research, and practice are included.

Analyzing women's roles through graphic representation of narratives.

A 1992 triangulated international nursing study of women's health was reported. The researchers used the perspectives of feminism and symbolic interactionism, specifically role theory. A narrative analysis was done to clarify the concept of role integration. The narrative analysis was reported in 1992, but graphic/visual techniques used in the team dialogue process of narrative analysis were not reported due to space limitations. These techniques have not been reported elsewhere and thus remain innovative. Specific steps in the method are outlined here in detail as an audit trail. The process would be useful to other qualitative researchers as an exemplar of one novel way that verbal data can be abstracted visually/graphically. Suggestions are included for aspects of narrative, in addition to roles, that could be depicted graphically in qualitative research.

Race and microaggression in nursing knowledge development.

Race is a social environmental element in many nursing knowledge contexts. We explore how race and racism have been conceptualized in nursing research and theory, situating these issues in the debate between Critical Race Theory and postracialism. Contemporarily, racism is more subtle than overt. Subtle racism takes the form of microaggressions in everyday discourse and practices by whites toward African Americans. This occurs with little to no awareness on the part of whites. Using this concept, practice and education are explored. We hold that microaggressions contribute to stress for the target person, which may partly account for racial health disparities.

Doctor shopping: a concept analysis.

Prescription drug abuse is a significant problem in the United States that poses a serious health risk to Americans and is therefore significant to the field of nursing. The prescription drugs that are designated in the United States as having abuse potential are called controlled or scheduled drugs. The most common types of abused prescription drugs are benzodiazepines prescribed for anxiety, opioids prescribed for pain, and stimulants prescribed for attention deficit disorder. These prescription drugs are abused by taking larger doses than prescribed for nonmedical use to achieve a high or euphoric feeling, or are sold illicitly for profit. In 2009, there were 2.4 million nonmedical users of prescription opioids in the United States. These prescription drugs are often obtained by seeing multiple prescribers, often under false pretenses or with complicity from the prescribers that leads to abuse and illicit sales. The term doctor shopping has been used not only to refer to this phenomenon but has also had other meanings throughout the past decades. Thus, concept analysis is the focus of this article for clarification using the Walker and Avant method. Health implications and suggestions for minimizing doctor shopping are included.

Exploring the concept of manliness in relation to the phenomenon of crying: a Bourdieusian approach.

The concept of manliness related to the phenomenon of crying can be better understood by tracing the roots of the language of manliness through history. A Bourdieusian theoretical approach is used, incorporating the analytics of habitus, bodily hexis, and symbolic violence. This less-studied phenomenon of crying is investigated from a holistic, biopsychosocial framework. Manliness is a social construct that has remained surprisingly consistent throughout history. The importance of this concept to physical, psychological, and social health and well-being is addressed from a holistic nursing perspective. This is a timely issue for men's mental health, for example, that of returning combat veterans experiencing loss, grief, and posttraumatic stress. This exploration provides insight for nursing by analyzing the concept of manliness, which stems largely from militaristic roots, and might present obstacles to emotional release.

Understanding the Person through Narrative.

Mental health nurses need to know their clients at depth, and to comprehend their social contexts in order to provide holistic care. Knowing persons through their stories, narratives they tell, provides contextual detail and person-revealing characteristics that make them individuals. Narratives are an everyday means of communicating experience, and there is a place for storytelling in nearly all cultures. Thus narrative is a culturally congruent way to ascertain and understand experiences. This means the nurse should ask questions such as "How did that come about?" versus why questions. A narrative approach stands in contrast to a yes/no algorithmic process in conversing with clients. Eliciting stories illustrates the social context of events, and implicitly provides answers to questions of feeling and meaning. Here we include background on narrative, insights from narrative research, and clinical wisdom in explaining how narratively understanding the person can improve mental health nursing services. Implications for theory, practice, and research are discussed.

To cry or not to cry: analyzing the dimensions of professional vulnerability.

In this article, the authors analyze the concept of professional vulnerability, as it relates to crying and the nursing profession. The span of potential professional vulnerability extends through all the nursing clinical, academic, and research environments. A dimensional analysis is the method used to analyze systematically how the concept of professional vulnerability is socially constructed and contextually situated in nursing. Professional vulnerability is demonstrated to have both negative and positive significances. Nurses' construction of vulnerability as a strength makes a significant difference in providing effective, positive holistic care. The objective of this analysis is to challenge the conventional views toward emotional and moral vulnerability in particular, leading to a holistic vision of hope and encouragement to benefit the future of nursing.

Crying that heals: concept evaluation.

Although much has been written about the healing power of tears, the research into this phenomenon has been fragmented, uncoordinated, and inconclusive. Nonetheless, a substantial amount of the literature across multiple disciplines has addressed the subject, both directly and indirectly. In this article, the authors submit crying that heals (CTH) as a concept of possible significance to health care and evaluate CTH using the criteria for concept evaluation proposed by Morse, Mitcham, Hupcey, and Tasón (1996). Using these criteria, CTH is tentatively defined, and its characteristics, boundaries, preconditions, and outcomes are proposed and examined in the context of this definition. Suggestions for additional analysis and research are offered, and the potential importance of CTH to health care professions, especially nursing, is discussed.