Canadian Nurse Practitioners' Therapeutic Commitment to Persons with Mental Illness.

The purpose of this study was to determine how Canadian nurse practitioners (NPs) rate their levels of therapeutic commitment, role competency, and role support when working with persons with mental health problems. A cross-sectional descriptive, co-relational design was used. The Therapeutic Commitment Model was the theoretical framework for the study. A sample of 680 Canadian NPs accessed through 2 territorial and 9 provincial nursing jurisdictions completed a postal survey. NPs scored highest on the therapeutic commitment subscale and lowest on the role support subscale. The 3 subscales were correlated: role competency and therapeutic commitment were the most strongly associated (r = .754, p < .001). To have a positive impact on the care of persons with mental health problems, educators, policy-makers, and NPs need to assess and support therapeutic commitment, role support, and role competency development.

Cette étude a pour objectif de déterminer la façon dont les infirmières praticiennes canadiennes (IP) déterminent leur degré d'engagement thérapeutique, leur compétence de rôle et leur soutien de rôle dans des contextes de travail avec des personnes atteintes de troubles de santé mentale. Un cadre descriptif transversal corelationnel a été utilisé. Le modèle d'engagement thérapeutique a servi de cadre théorique. Un échantillon de 680 IP canadiennes recrutées dans deux juridictions territoriales et neuf juridictions provinciales infirmières ont rempli un sondage envoyé par la poste. Les IP ont obtenu le score le plus élevé quant à la sous-échelle de l'engagement thérapeutique et le score le plus faible quant à la sous-échelle du soutien de rôle. Les trois sous-échelles ont été corrélées: la compétence de rôle et l'engagement thérapeutique affichaient l'association la plus élevée (r = 0,754, p < 0,001). Pour assurer un impact positif sur les soins aux personnes atteintes de troubles de santé mentale, les éducateurs, les décideurs et les IP doivent évaluer et soutenir l'engagement thérapeutique, le soutien de rôle et le développement de compétences de rôle.

Health experiences of Korean immigrant women in retirement.

In this focused ethnographic study, we explored the health experiences of 15 Korean immigrant women after retirement in an urban center in Western Canada. Almost all women began their lives in Canada without adequate personal finances, making their employment essential for supporting their families financially. Most women lived with more than two chronic diseases, attributed to long hours and difficult work conditions. They experienced improved psychological health after retiring, irrespective of positive or negative changes in their physical health. Spiritual faith and exercise were important strategies to maintain and enhance their health and to postpone and manage chronic diseases.

The experience of Korean immigrant women adjusting to Canadian society.

The acculturation process is an important factor in the experience of all immigrants. Although previous studies have indicated the challenges faced by Korean immigrants, little attention has been paid to Korean women's immigration experiences. A focused ethnography was used to examine midlife and older Korean immigrant women's experiences following their immigration to Canada. Fifteen women were interviewed in a city in Western Canada. The findings showed that in coming to Canada, women focused on caring for their children and often sacrificed their personal dreams. They had to be employed to support their families, and received support from family and government. Women participated regularly in a Korean Church and drew on their Christian faith to ease their adjustment. They retained hopes for the future including good health and a better life for their children. Most women indicated that it was difficult to integrate into Canadian society but they never gave up on their adjustment to a new culture. In this manuscript, the adjustment experience of the immigrant women is discussed in the context of an acculturation framework. The findings will enhance health professionals' awareness of adjustment patterns and associated challenges to Korean immigrant women's quality of life.

The experience of HIV diagnosis among Aboriginal people living with HIV/AIDS and depression.

In this article, we consider how the broad context of Aboriginal people's lives can shape their experience and understanding of their HIV diagnosis. We conducted interviews across Canada with 72 Aboriginal people living with HIV who also reported feelings of depression. Consistent with what has been found in previous studies, participants responded to their HIV diagnosis with shock, disbelief, and often anger. Prior depression, drug and alcohol use, multiple losses, stigma, and social isolation also shaped how participants experienced their diagnosis. We consider how the history of colonization of Aboriginal communities in Canada relates to the experience of HIV diagnosis, and end with a discussion of the service implications of our findings.

Stigma in AIDS nursing care in sub-saharan Africa and the Caribbean.

Some nurses who provide AIDS care, in addition to experiencing stigma themselves, also exhibit negative attitudes and perpetrate stigma and discrimination toward persons living with HIV (PLWHAs). We used a participatory research approach to explore the nature, context, and influence of stigma on the nursing care provided to PLWHAs in four low- and middle-income countries: Jamaica, Kenya, South Africa, and Uganda. Eighty-four registered nurses, enrolled nurses, and midwives participated in interviews and 79 participated in 11 focus groups. Nurses were very aware of the stigma and discrimination that AIDS evoked, and made adjustments to their care to decrease the manifestation of AIDS stigma. Despite the assurance that PLWHAs were treated equally, and that universal precautions were used consistently, we found that in reality, nurses sometimes made decisions about nursing care that were based on the appearance of the patient or knowledge of his or her status.

HIV testing experiences of Aboriginal youth in Canada: service implications.

The objective of this study was to explore HIV testing experiences and service views of Canadian Aboriginal youth in order to provide information for HIV testing services. An exploratory, mixed-method, community-based research design was used for this study. Findings reported here are from 210 survey participants who had experienced an HIV test. Youth were recruited through 11 Aboriginal organizations across Canada, including AIDS service organizations, health centers, community organizations, and friendship centers. Youth who had tested for HIV ranged in age from 15 to 30 years of age (20% were <20), and came from First Nations (75%), Metis (14%), and Inuit (9%) backgrounds. Participants lived in all provinces and one territory. Over half (62%) were female. While the majority of survey respondents indicated at their last HIV test they had been treated with care (80%), respect (77%), or kindness (76%), some reported being treated with hostility (19%), fear (12%), discrimination (11%), avoidance (10%), or being treated in a bored way (15%). When asked about information they had received, 28% of survey respondents could not remember; 23% said they were not given any information, and 24% said their questions were not answered. Emotional reactions to testing ranged from anxiety/apprehension (64% of survey respondents) to being "calm" (19%). When asked for suggestions to improve testing services, participants indicated emotional support, compassion, professional yet personable services, and personalized HIV information were important. Study results suggest that to facilitate HIV testing for Aboriginal youth, testing services and counseling must be respectful, compassionate, non-judgmental, and culturally responsive in order to provide emotional support and HIV information that is meaningful and memorable.

Stigmatization as a social control mechanism for persons living with HIV and AIDS.

Stigmatization contributes to inequity by marginalizing persons living with HIV and AIDS (PHAs). In this study we examined the stigmatizing practices in health care settings from the perspectives of PHAs and health care providers (HCPs). A qualitative design, using a participatory action research approach, was used. Interviews and focus groups were completed with 16 aboriginal and 17 nonaboriginal individuals living with HIV (APHAs and PHAs) and 27 HCPs in Ottawa and Edmonton, Canada. We present findings to support the premise that stigmatization can be used as a social control mechanism with PHAs. Participants described both active and passive social control mechanisms: shunning and ostracizing, labeling, and disempowering health care practices. Forgiving behavior, balancing disclosure, practicing universal precautions, bending the rules, shifting services, and reducing labeling were strategies to manage, resist, and mitigate social control. The findings illustrate the urgent need for multilevel interventions to manage, resist, and mitigate stigma.

Accessing health services while living with HIV: intersections of stigma.

AIDS stigma has serious consequences. This study explored those practices within health-care organizations that persons with HIV perceive as stigmatizing. It used an exploratory, descriptive design using a participatory action research approach. Interviews and focus groups were conducted with 16 Aboriginal and 17 non-Aboriginal persons living with HIV as well as with 27 health-care providers. The AIDS stigma perceived by many participants often intersected with other forms of stigma, related to behaviour, culture, gender, sexual orientation, or social class. In addition, policies at the organizational level contributed to AIDS stigma and at times intersected with stigma at the individual level. Participants' experiences of stigma and discrimination were shaped by the organizational policies (universal precautions, models of care) and design (physical layout) under which care was provided. Several paradoxes associated with secrecy, health-care settings, and the layering of stigma emerged in the reported experiences.

Cervical screening in Canadian First Nation Cree women.

PURPOSE: Attitudes and beliefs of First Nation Cree women living in a reserve community were explored to gain insights into how cervical screening could be better utilized. METHOD: Focused ethnography utilizing participant observation and interviews ( n = 8) with participants having experience with cervical screening and/or cancer was conducted. RESULTS: Women did not believe they had adequate information and were resistant to screening because of embarrassment caused by the procedure and fear of cancer, which was viewed as a "death sentence." CONCLUSIONS: Challenges faced by First Nation Cree women when contemplating cervical screening are presented. Nursing sensitivity is needed to strategize access to cervical screening that is culturally appropriate.

HIV testing and care in Canadian Aboriginal youth: a community based mixed methods study.

BACKGROUND: HIV infection is a serious concern in the Canadian Aboriginal population, particularly among youth; however, there is limited attention to this issue in research literature. The purpose of this national study was to explore HIV testing and care decisions of Canadian Aboriginal youth. METHODS: A community-based mixed-method design incorporating the Aboriginal research principles of Ownership, Control, Access and Possession (OCAP) was used. Data were collected through surveys (n = 413) and qualitative interviews (n = 28). Eleven community-based organizations including urban Aboriginal AIDS service organizations and health and friendship centres in seven provinces and one territory assisted with the recruitment of youth (15 to 30 years). RESULTS: Average age of survey participants was 21.5 years (median = 21.0 years) and qualitative interview participants was 24.4 years (median = 24.0). Fifty-one percent of the survey respondents (210 of 413 youth) and 25 of 28 interview participants had been tested for HIV. The most common reason to seek testing was having sex without a condom (43.6%) or pregnancy (35.4%) while common reasons for not testing were the perception of being low HIV risk (45.3%) or not having had sex with an infected person (34.5%). Among interviewees, a contributing reason for not testing was feeling invulnerable. Most surveyed youth tested in the community in which they lived (86.5%) and 34.1% visited a physician for the test. The majority of surveyed youth (60.0%) had tested once or twice in the previous 2 years, however, about one-quarter had tested more than twice. Among the 26 surveyed youth who reported that they were HIV-positive, 6 (23.1%) had AIDS at the time of diagnosis. Delays in care-seeking after diagnosis varied from a few months to seven years from time of test. CONCLUSION: It is encouraging that many youth who had tested for HIV did so based on a realistic self-assessment of HIV risk behaviours; however, for others, a feeling of invulnerability was a barrier to testing. For those who tested positive, there was often a delay in accessing health services.

Nursing care of AIDS patients in Uganda.

This article reports the findings from a participatory action research study concerning the experience of Ugandan nurses caring for individuals with HIV illness. Six key informants from government and non-governmental organizations were interviewed using a semistructured format. Six nurses from a large national referral hospital in Kampala, Uganda, participated in 10 focus group meetings during a period of 11 months. In-depth interviews, focus groups, and photovoice were used to collect the data. Findings indicate that nurses faced many challenges in their daily care, including poverty, insufficient resources, fear of contagion, and lack of ongoing education. Nurses experienced moral distress due to the many challenges they faced during the care of their patients. Moral distress may lead nurses to quit their jobs, which would exacerbate the acute shortage of nurses in Uganda. This study provides important knowledge for guiding clinical practice and nursing education in resource-constrained countries like Uganda.

Lipodystrophy syndrome associated with antiretroviral therapy in HIV patients: considerations for psychosocial aspects.

Several side effects have been strongly associated with antiretroviral therapy in HIV patients. Among them, the lipodystrophy syndrome which presents alterations in body shape with central adipose hypertrophy and peripheral lipoatrophy, reported by patients as a visible marker identifying them as HIV patients. This manuscript presents an analysis of current literature regarding the psychosocial aspects of HIV patients with lipodystrophy associated with antiretroviral therapy. The results show that the alterations in body shape can be disturbing in terms of psychosocial well being, affecting quality of life and increasing the stigma associated with the disease, with consequent disturbances in social relations. This analysis provides a preliminary review of the psychosocial aspects of lipodystrophy and further studies are needed for a better understanding of this complex syndrome, which could provide new information to be used in nursing care for HIV patients affected by this problem.

Relationship between characteristics of volunteer community health workers and antiretroviral treatment outcomes in a community-based treatment programme in Uganda.

Community health workers (CHWs) can help to redress the shortages of health human resources needed to scale up antiretroviral treatment (ART). However, the selection of CHWs could influence the effectiveness of a CHW programme. The purpose of this observational study was to assess whether sociodemographic characteristics and geographic proximity to patients of volunteer CHWs were predictors of clinical outcomes in a community-based ART (CBART) programme in Kabarole, Uganda. Data from CHW surveys for 41 CHWs and clinic charts for 185 patients in the CBART programme were analysed using multivariable logistic and Cox regression models. Time to travel to patients was the only statistically significant characteristic of CHWs associated with ART outcomes. Patients whose CHWs had to travel one or more hours had a 71% lower odds of virologic suppression (adjusted OR = 0.29, 95% CI = 0.13-0.65, p = .002) and a 4.52 times higher mortality hazard rate (adjusted HR = 4.52, 95% CI = 1.20-17.09, p = .026) compared to patients whose CHWs had to travel less than one hour. The findings show that the sociodemographic characteristics of CHWs were not as important as the geographic distance they had to travel to patients.

Stigma associated with Ghanaian caregivers of AIDS patients.

This study explores the experiences of informal caregivers of AIDS patients in Accra, the capital city of Ghana. Fifteen interviews were completed in 2002 with 11 informal caregivers, including wives, mothers, boyfriends, daughters, sons and brothers of AIDS patients. Three major themes emerge in the analysis of the interviews with caregivers: stigma, caregiver burden, and caregiver commitment. In this article, the authors focus on the theme of stigma by documenting its presence and highlighting its impact on caregiving activities. Caregivers go to great effort to not only "hide" their patients but also their care giving activities, resulting in the social isolation of both patients and their caregivers. Many caregivers live in secrecy, not sharing their family member's diagnosis with extended family members. As a result, they receive limited support from the extended family. Stigma results in negative attitudes of neighbors, relatives, and health care workers toward caregivers and their patients.

Family caregiving for AIDS patients in the Democratic Republic of Congo.

We conducted a qualitative study of women who were caregivers for HIV/AIDS-affected spouses in Bumbu Zone, Kinshasa, Democratic Republic of Congo in 2003. Twelve caregiving women, six home-based care workers and five key informants were interviewed via focus group discussions. Most women reported huge problems in providing care to their spouses due to psychological, social and economic factors. The secrecy around HIV/AIDS issues and care was a significant theme in the findings. The self-reported health status of the caregivers indicated poor health.

A systematic review of best practices in HIV care.

Best practices in HIV care have the potential to improve patient outcomes and inform practice. We conducted a systematic review of best practices in HIV care that were published from 2003 to 2013. Practices that demonstrated success in achieving desired results based on their objectives were included in the review. Two themes emerged from the eight articles reviewed: (a) the importance of linking newly diagnosed people living with HIV to care and (b) the role of integrated and comprehensive service provision in improving patient outcomes. Inconsistencies in reporting and arbitrary use of the term "best practices" were hurdles in this review.

Exploring the meaning of living with HIV as a chronic illness in Kenya: A narrative inquiry.

Since the introduction of antiretroviral medications, HIV has been regarded as a chronic illness. However, people living with HIV continue to experience social consequences of HIV infection such as stigma, discrimination, violence, and other human rights violations. In this paper, we focus on the experiences of Atoti, a person living with HIV in Kenya. We argue that HIV remains a biographically disruptive and exceptional illness that is complicated by its invisibility and unpredictable trajectory. Based on Atoti's experiences, we argue that Bury's (1982) concept of biographical disruption, used to explain the social processes of a person suffering a chronic illness, does not fully capture the complexity of experiencing living with HIV. Focusing on life as a whole, rather than on the disease response and process as a biographical disruption, allows for a deeper appreciation of HIV's complexity as a medical illness with major social ramifications.

A Mixed-Methods Outcome Evaluation of a Mentorship Intervention for Canadian Nurses in HIV Care.

We assessed the impact of an HIV care mentorship intervention on knowledge, attitudes, and practices with nurses and people living with HIV (PLWH) in Canada. We implemented the intervention in two urban and two rural sites with 16 mentors (eight experienced HIV nurses and eight PLWH) and 40 mentees (nurses with limited HIV experience). The 6- to 12-month intervention included face-to-face workshops and monthly meetings. Using a mixed-methods approach, participants completed pre- and postintervention questionnaires and engaged in semistructured interviews at intervention initiation, mid-point, and completion. Data from 28 mentees (70%) and 14 mentors (87%) were included in the quantitative analysis. We analyzed questionnaire data using McNemar test, and interview data using content analysis. Results indicated positive changes in knowledge, attitudes, and practices among nurse mentees, with qualitative interviews highlighting mechanisms by which change occurred. Mentorship interventions have the potential to engage and educate nurses in HIV treatment and care.

The impact of leadership hubs on the uptake of evidence-informed nursing practices and workplace policies for HIV care: a quasi-experimental study in Jamaica, Kenya, Uganda and South Africa.

BACKGROUND: The enormous impact of HIV on communities and health services in Sub-Saharan Africa and the Caribbean has especially affected nurses, who comprise the largest proportion of the health workforce in low- and middle-income countries (LMICs). Strengthening action-based leadership for and by nurses is a means to improve the uptake of evidence-informed practices for HIV care. METHODS: A prospective quasi-experimental study in Jamaica, Kenya, Uganda and South Africa examined the impact of establishing multi-stakeholder leadership hubs on evidence-informed HIV care practices. Hub members were engaged through a participatory action research (PAR) approach. Three intervention districts were purposefully selected in each country, and three control districts were chosen in Jamaica, Kenya and Uganda. WHO level 3, 4 and 5 health care institutions and their employed nurses were randomly sampled. Self-administered, validated instruments measured clinical practices (reports of self and peers), quality assurance, work place policies and stigma at baseline and follow-up. Standardised average scores ranging from 0 to 1 were computed for clinical practices, quality assurance and work place policies. Stigma scores were summarised as 0 (no reports) versus 1 (one or more reports). Pre-post differences in outcomes between intervention and control groups were compared using the Mantel Haenszel chi-square for dichotomised stigma scores, and independent t tests for other measures. For South Africa, which had no control group, pre-post differences were compared using a Pearson chi-square and independent t test. Multivariate analysis was completed for Jamaica and Kenya. Hub members in all countries self-assessed changes in their capacity at follow-up; these were examined using a paired t test. RESULTS: Response rates among health care institutions were 90.2 and 80.4 % at baseline and follow-up, respectively. Results were mixed. There were small but statistically significant pre-post, intervention versus control district improvements in workplace policies and quality assurance in Jamaica, but these were primarily due to a decline in scores in the control group. There were modest improvements in clinical practices, workplace policies and quality assurance in South Africa (pre-post) (clinical practices of self-pre 0.67 (95 % CI, 0.62, 0.72) versus post 0.78 (95 % CI, 0.73-0.82), p = 0.002; workplace policies-pre 0.82 (95 % CI, 0.70, 0.85) versus post 0.87 (95 % CI, 0.84, 0.90), p = 0.001; quality assurance-pre 0.72 (95 % CI, 0.67, 0.77) versus post 0.84 (95 % CI, 0.80, 0.88)). There were statistically significant improvements in scores for nurses stigmatising patients (Jamaica reports of not stigmatising-pre-post intervention 33.9 versus 62.4 %, pre-post control 54.7 versus 64.4 %, p = 0.002-and Kenya pre-post intervention 35 versus 51.6 %, pre-post control 34.2 versus 47.8 %, p = 0.006) and for nurses being stigmatised (Kenya reports of no stigmatisation-pre-post intervention 23 versus 37.3 %, pre-post control 15.4 versus 27 %, p = 0.004). Multivariate results for Kenya and Jamaica were non-significant. Twelve hubs were established; 11 were active at follow-up. Hub members (n = 34) reported significant improvements in their capacity to address care gaps. CONCLUSIONS: Leadership hubs, comprising nurses and other stakeholders committed to change and provided with capacity building can collectively identify issues and act on strategies that may improve practice and policy. Overall, hubs did not provide the necessary force to improve the uptake of evidence-informed HIV care in their districts. If hubs are to succeed, they must be integrated within district health authorities and become part of formal, legal organisations that can regularise and sustain them.