Toward Treatment Integrity: Developing an Approach to Measure the Treatment Integrity of a Dialectical Behavior Therapy Intervention With Homeless Youth in the Community.

The current paper discusses an approach to measuring treatment integrity of dialectical behavioral therapy (DBT) when implemented within two programs providing services to street-involved youth in the community. Measuring treatment integrity is a critical component of effective implementation of evidence-based interventions in clinical practice, since sound treatment integrity increases confidence in client outcomes and intervention replicability. Despite being an essential part of implementation science, few studies report on treatment integrity, with limited research addressing either measurement tools or maintenance of treatment integrity. To address the lack of available treatment integrity measures, researchers in the current study developed and piloted a treatment integrity measure which pertain to the individual and group components of DBT. A total of 20 recordings were assessed using the treatment integrity measure. Results indicate that the community agency staff (e.g. youth workers, social workers & nurses) implemented the intervention as intended; increasing confidence in the outcome variables, the staffs' training and the replicability of the intervention. This article offers one approach to addressing treatment integrity when implementing evidence-based interventions, such as DBT in a community setting, and discusses the need for effective and feasible integrity measures that can be adopted in order to strengthen mental health practice in community settings.

The experience of developing a faculty research cluster using the creativity of the narrative reflective process.

Faculty development that builds research capacity is a significant yet challenging expectation in academia. The School of Nursing faculty at Ryerson University established several research clusters to support research collaborations and productivity. This article explicates one cluster's development process, and specifically, its adoption of the narrative reflective process (NRP). Engaging in NRP permitted the group to creatively enter into critical dialogue, address both individual and collective needs, and establish a supportive environment that nurtures the creative process--all of which ultimately enhances scholarship and academic productivity.

Self-monitoring of blood glucose in Black Caribbean and South Asian Canadians with non-insulin treated Type 2 diabetes mellitus: a qualitative study of patients' perspectives.

BACKGROUND: To examine the views and current practice of SMBG among Black Caribbean and South Asian individuals with non-insulin treated Type 2 diabetes mellitus. METHODS: Twelve participants completed semi-structured interviews that were guided by the Health Belief Model and analyzed using thematic network analysis. RESULTS: The frequency of monitoring among participants varied from several times a day to once per week. Most participants expressed similar experiences regarding their views and practices of SMBG. Minor differences across gender and culture were observed. All participants understood the benefits, but not all viewed SMBG as beneficial to their personal diabetes management. SMBG can facilitate a better understanding and maintenance of self-care behaviours. However, it can trigger both positive and negative emotional responses, such as a sense of disappointment when high readings are not anticipated, resulting in emotional distress. Health care professionals play a key role in the way SMBG is perceived and used by patients. CONCLUSION: While the majority of participants value SMBG as a self-management tool, barriers exist that impede its practice, particularly its cost. How individuals cope with these barriers is integral to understanding why some patients adopt SMBG more than others.

The development of recovery competencies for in-patient mental health providers working with people with serious mental illness.

Delivering recovery-oriented services is particularly challenging in in-patient settings. The purpose of this study was to identify the most salient recovery competencies required of in-patient providers. Established methods for the development of competencies were used. Data collection included interviews with multiple stakeholders and a literature review. Data analysis focused on understanding how characteristics of the in-patient context influence recovery-enabling service delivery and the competencies associated with addressing these issues. Eight core competencies with four to ten sub-competencies were identified based on a tension-practice-consequence model. The competency framework can serve as a tool for tailoring workforce education.

A cyborg ontology in health care: traversing into the liminal space between technology and person-centred practice.

Person-centred practice indubitably seems to be the antithesis of technology. The ostensible polarity of technology and person-centred practice is an easy road to travel down and in their various forms has been probably travelled for decades if not centuries. By forging ahead or enduring these dualisms, we continue to approach and recede, but never encounter the elusive and the liminal space between technology and person-centred practice. Inspired by Haraway's work, we argue that healthcare practitioners who critically consider their cyborg ontology may begin the process to initiate and complicate the liminal and sought after space between technology and person-centred practice. In this paper, we draw upon Haraway's idea that we are all materially and ontologically cyborgs. Cyborgs, the hybridity of machine and human, are part of our social reality and embedded in our everyday existence. By considering our cyborg ontology, we suggest that person-centred practice can be actualized in the contextualized, embodied and relational spaces of technology. It is not a question of espousing technology or person-centred practice. Such dualisms have been historically produced and reproduced over many decades and prevented us from recognizing our own cyborg ontology. Rather, it is salient that we take notice of our own cyborg ontology and how technological, habitual ways of being may prevent (and facilitate) us to recognize the embodied and contextualized experiences of patients. A disruption and engagement with the habitual can ensure we are not governed by technology in our logics and practices of care and can move us to a conscious and critical integration of person-centred practice in the technologized care environments. By acknowledging ourselves as cyborgs, we can recapture and preserve our humanness as caregivers, as well as thrive as we proceed in our technological way of being.

Experience of emotional stress and resilience in street-involved youth: the need for early mental health intervention.

Mental illness left untreated in adolescence and young adulthood can readily become a chronic illness in adulthood, seriously hampering the capacity of individuals to become healthy contributing members of society. Mental health challenges are of paramount importance to the health and well-being of Canadian adolescents and young adults, with 18% of Canadian youth, ages 15-24, reporting a mental illness (Leitch 2007). However, it is unlikely that this statistic accounts for those invisible youth (Rachlis et al. 2009) who are disconnected from families and caregivers, bereft of stable housing and familial support - in other words, youth who are street-involved. Mental health risk is amplified in street-involved youth and, as such, must be recognized as a priority for policy development that commits to accessible mental health programming, in order to realize the potential of these vulnerable youth.

What we know - and want to know - about Family Connections: a review from the perspective of lived experience.

Family Connections is a peer-led education, skills, and support program for family members of individuals with borderline personality disorder. Extant literature on Family Connections is limited but consistent in regard to methodology and outcomes, allowing for meaningful cross-study comparison. Despite evidence across studies regarding the program's efficacy, a number of questions remain to be answered. Three possible future research directions were identified from the perspective of family members with lived experience who are also Family Connections peer leaders; examining Family Connections when led by peers, gathering qualitative data about family member's experiences of Family Connections to illuminate additional program benefits, and studying the efficacy of Family Connections for family members of those with other mental health disorders.

Exploring Undergraduate Nursing Students' Experiences of Engaging With a Dialectical Behavior Therapy-Skills Group Intervention: Findings of a Thematic Analysis.

STUDY BACKGROUND: Nursing students often have high levels of stress leading to negative consequences for academic performance and overall well-being. Novel strategies are needed to help students manage stress. PURPOSE: To explore students' experiences with an evidence-based intervention-Dialectical Behavior Therapy-Skills Group (DBT-SG). METHODS: We conducted a mixed-methods study to pilot test a DBT-SG intervention, modified for use with undergraduate nursing students. Qualitative data collected as part of this study included focus groups and written responses on a study questionnaire. Thematic analysis of these data was undertaken to explore how students experienced the intervention. The results of this analysis are reported here. RESULTS: Five themes were uncovered: experiencing stress and de-stressing, feeling accepted and validated, acquiring skills, shifting perspectives, and enhanced well-being. CONCLUSIONS: Our findings suggest that by engaging with DBT-SG, nursing students felt accepted and validated, acquired a variety of skills to cope with stress, as well as developed new perspectives, such as the value of practicing self-care, which contributed to enhanced well-being. Future research could build on these results by further exploring how to best create accepting and validating learning environments where students are encouraged to develop interpersonal relationship skills and enact self-care to further support their well-being and professional development.

Mental health challenges and strengths of street-involved youth: the need for a multi-determined approach.

The social environments and activities of homeless youth frequently create a downward spiral, leading to drug abuse and survival sex as well as self-harm behaviours and suicidality. This study employed a mixed-methods approach to assess the mental health challenges and strengths of street-involved youth. A convenience sample of 70 homeless young people completed a series of standardized questionnaires evaluating mental health symptoms as well as resilience and self-esteem. Two focus groups were also held to capture the perceived mental health needs of street-involved youth. These young people (aged 16-24) were found to have high levels of mental health symptoms compared to other groups of young adults. However, they also exhibited moderately high levels of resilience and self-esteem. Therefore, multi-component mental health programs and interventions that address both strengths and challenges may well help street-involved youth to work towards social re-integration and, ultimately, improved quality of life.

Through the Lens of Chronic Kidney Disease: A Qualitative Study of the Experiences of Young Women Living With CKD.

BACKGROUND: Young women may be particularly vulnerable to the negative psychosocial consequences of living with chronic kidney disease (CKD). To date, little is known about how women themselves experience and manage their illness. OBJECTIVES: This study explored the experiences of young women living with CKD. DESIGN: Qualitative descriptive study. SETTING: Nephrology program in an urban setting in Ontario, Canada. PARTICIPANTS: Women with category G1-3 glomerular-based CKD between 18 and 40 years of age. METHODS: Focus group discussions guided by semi-structured interview questions. Qualitative content analysis was used to analyze interview transcripts. RESULTS: Eleven women participated in 3 separate focus group discussions. Participants described living life through the lens of CKD, which was the central theme unifying their experiences of encountering CKD, re-encountering CKD, and getting on with life. Life decisions significant to women like pursuing a career or motherhood were often colored by CKD, particularly by illness-related challenges, such as unsatisfactory health care support and the physical implications of chronic illness. The women used a variety of strategies including seeking information and relying on supportive people to mitigate these challenges. Although these strategies sometimes enabled them to balance the demands of illness with other life priorities, the lack of resources directed toward their unique needs as young women with CKD often caused them difficulties in managing their illness. LIMITATIONS: Participants were from one nephrology program in an urban setting and were well educated overall. Their experiences may not be reflective of young women in other settings or from diverse backgrounds. CONCLUSIONS: The women's emotional well-being and life choices were considerably influenced by CKD. Although the women were often able to manage challenges associated with CKD, they acknowledged the need to seek additional professional resources to complement their own self-identified strategies. As the women sought out these supports, they identified gaps in resources specific to women with CKD. This article summarizes recommendations from their perspective. TRIAL REGISTRATION: Not applicable as this was a qualitative study.

CONTEXTE: Les jeunes femmes seraient particulièrement vulnérables aux effets psychologiques négatifs de vivre avec l'insuffisance rénale chronique (IRC). À ce jour, on en sait peu sur l'expérience vécue par ces femmes et sur la façon dont elles gèrent la maladie. OBJECTIF: L'étude s'est penchée sur l'expérience de jeunes femmes vivant avec l'IRC. TYPE D'ÉTUDE: Étude qualitative et descriptive. CADRE: Le programme de néphrologie d'un centre urbain en Ontario (Canada). SUJETS: Des femmes âgées de 18 à 40 ans atteintes d'IRC glomerulaire de catégorie G1 à G3. MÉTHODOLOGIE: Discussions sous forme d'entretiens semi-structurés en groupes-échantillons et évaluation des transcriptions par l'analyse qualitative de contenu. RÉSULTATS: Les participantes (n=11) ont pris part à trois groupes de discussion distincts. Elles ont décrit leur expérience à travers le prisme de l'IRC, le thème principal des discussions, et discuté des premières manifestations de la maladie, des épisodes récurrents et de la poursuite de leur vie malgré la maladie. Les décisions de vie importantes, notamment la maternité et la poursuite d'une carrière, ont bien souvent été teintées par l'IRC et ses défis, en particulier par le manque de soutien en matière de soins de santé et par les conséquences physiques de vivre avec une maladie chronique. Des défis qu'elles ont tenté d'atténuer par diverses stratégies, notamment par la recherche d'information et d'appui de la part de personnes de confiance. Bien que ces stratégies leur ont permis à l'occasion de créer un équilibre entre les exigences de la maladie et les autres priorités de leur vie, le manque de ressources répondant à leurs besoins particuliers a rendu la gestion de la maladie plus difficile. LIMITES: Les participantes provenaient d'un seul programme de néphrologie en milieu urbain et étaient dans l'ensemble bien éduquées. L'expérience décrite pourrait ne pas refléter celle de jeunes femmes issues de milieux et de contextes différents. CONCLUSION: L'IRC a considérablement influencé les choix de vie et le bien-être psychologique des jeunes femmes questionnées. Bien qu'elles arrivent généralement à surmonter les défis liés à la maladie, les participantes, en cherchant des ressources pour appuyer leurs stratégies, ont constaté des lacunes dans les ressources professionnelles destinées spécifiquement aux jeunes femmes atteintes d'IRC. Cet article résume les recommandations de leur point de vue. ENREGISTREMENT DE L'ESSAI: Ne s'applique pas puisqu'il s'agit d'une étude qualitative.

Prepared for transition? A cross-sectional descriptive study of the gains attained in early psychosis programs.

AIM: To examine the degree to which youth identified as ready for discharge from three Canadian early psychosis intervention (EPI) programs had achieved optimal outcomes (ie, symptom remission, quality of life, self-esteem and functioning). METHODS: This cross-sectional descriptive study is part of a larger study assessing the effectiveness of an evidence-based intervention to sustain the gains acquired in EPI programs in two Canadian provinces (Ontario and Nova Scotia), as youth transition from EPI services to community-based care. Baseline data collected from 39 participants receiving usual treatment in these three EPI programs comprised the comparison group. Participants completed measures to assess symptoms, quality of life, self-esteem and functional level just prior to discharge. RESULTS: Participants demonstrated lower levels of symptoms, greater quality of life, greater self-esteem and greater levels of functioning, following EPI treatment when compared to similar youth described in the literature. These findings suggest that study participants had achieved optimal outcomes following EPI treatment. CONCLUSION: The study findings have laid the ground work for the current Canadian Institutes of Health Research partnership study in which our research group is assessing the effectiveness of an evidence-based transitional intervention in order to address critical psychosocial issues of identity, stigma, effective relationships and meaningful life goals, along with the development of an individualized 'passport for transition'. It is anticipated that implementing an evidence-based transitional intervention will support participants to maintain the gains made in EPI programs once they transition to community-based care and will inform future research addressing this challenging issue.

Evaluating the Effects of a Rent Subsidy and Mentoring Intervention for Youth Transitioning Out of Homelessness: Protocol for a Mixed Methods, Community-Based Pilot Randomized Controlled Trial.

BACKGROUND: Although the risk factors associated with young people entering and becoming entrenched in street life have been thoroughly investigated, peer-reviewed evidence is scarce to nonexistent for rigorous interventions targeting social integration outcomes for young people who have experienced homelessness. From the limited research that has been done, emerging evidence signals that, although structural supports such as subsidized housing and social service providers are important, these resources alone are insufficient to help young people integrate into the mainstream society. OBJECTIVE: The overarching aim of this study is to assess whether and how rent subsidies and mentorship influence social integration outcomes for formerly homeless young people living in market rent housing in 3 Canadian cities. The primary outcome measures for this study are community integration (psychological and physical) and self-esteem at 18 months. Secondary outcomes include social connectedness, hope, and academic and vocational participation at 18 months. Exploratory outcomes include income, perceived housing quality, engulfment, psychiatric symptoms, and participant perspectives of intervention barriers and facilitators. METHODS: This is a convergent mixed methods, open-label, 2-arm parallel randomized controlled trial (RCT) with 1:1 allocation embedded within a community-based participatory action research (CBPAR) framework. The intervention will provide 24 young people (aged 16-26 years), who have transitioned out of homelessness and into market rent housing within the past year, with rent subsidies for 24 months. Half of the young people will also be randomly assigned an adult mentor who has been recruited and screened by 1 of our 3 community partners. Data collection will occur every 6 months, and participants will be followed for 30 months. RESULTS: Ethical approval for this study has been obtained from the Providence, St Joseph's, and St Michael's Healthcare Research Ethics Board (number 18-251). Enrollment took place from April 2019 to September 2019. Preliminary analysis of the baseline quantitative and qualitative data is underway. CONCLUSIONS: This pilot RCT will be the first to test the impact of economic and social support on meaningful social integration for formerly homeless young people living in market rent housing. We believe that the mixed methods design will illuminate important contextual factors that must be considered if the intervention is to be scaled up and replicated elsewhere. Importantly, the CBPAR framework will incorporate the perspectives of the community, including formerly homeless young people, who are in the best position to determine what might work best in the context of their lives. TRIAL REGISTRATION: Clinicaltrials.gov NCT03779204; https://clinicaltrials.gov/ct2/show/NCT03779204. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/15557.

Decreasing stress and supporting emotional well-being among senior nursing students: A pilot test of an evidence-based intervention.

BACKGROUND: Nursing students can experience stress related to their academic and practice experiences, which can have deleterious effects on physical and emotional well-being. OBJECTIVES: To pilot test an evidence-based intervention, Dialectical Behavior Therapy-Skills Group, designed to promote emotional well-being among nursing students. DESIGN: A single group, pre-posttest design, mixed-method approach. SETTING: A large university situated in a multicultural urban setting. PARTICIPANTS: Senior undergraduate nursing students (n = 31). METHODS: Students participated in an 8-week modified Dialectical Behavior Therapy-Skills Group (DBT-SG) intervention. Quantitative and qualitative data were collected to explore the interventions' feasibility, acceptability, and students' perceptions of its applicability to practice. Students also completed standardized outcome measures of psychological distress and emotional well-being pre- and post-intervention to evaluate preliminary effectiveness. RESULTS: Overall feedback was positive, with participants describing how skill modules helped them establish relationships and manage stress in clinical, academic, and personal settings. Significant reductions in stress and improvements in well-being were also reported. CONCLUSION: Results suggest that DBT-SG offers a promising approach for mitigating nursing students' stress by helping them acquire practice-relevant strengths and self-care strategies. Further research is required to examine the effectiveness of DBT-SG among other nursing student groups, as well as to explore optimal approaches to delivering this intervention in conjunction with nursing curricula.

Exploring parent participation in a parent training program for children's aggression: understanding and illuminating mechanisms of change.

PROBLEM: Controlled trials have demonstrated that parents of children experiencing high levels of aggression benefit greatly from parent training programs. Several programs have shown a decrease in parental stress, an increase in parental confidence, and higher levels of prosocial behavior in children as shown by outcomes based on quantitative measures. However, less attention has been paid to the views and experiences of parents themselves about the impact of such programs on themselves, their children, and their parent-child relationships. METHODS: The purpose of this qualitative study was to elicit and explore parents' perceptions of the effectiveness of the Incredible Years Parent Training Program. Following their participation in the Incredible Years Program, 37 parents completed a semistructured interview and completed demographic questionnaires. Data were analyzed employing a content analysis of the transcripts and descriptive statistics of the demographic data. FINDINGS: Parents strongly valued the support offered within the group therapy process, reporting a decrease in their stress levels, an increase in their confidence, as well as observing positive changes in their children and in the parent-child relationship. CONCLUSIONS: The findings of this research illuminate possible underlying mechanisms for these observed changes. Specifically, when parents feel accepted, supported, and not blamed by healthcare professionals, they seem to be able to engage in self-reflection specifically related to their parenting styles. In turn, their ability to reflect in the group and make sense of their own thoughts, feelings, and behaviors seems to have a positive influence on the process of change in themselves, their children, and in their relationships with their children and other family members.

The self-management experience of people with mild to moderate chronic kidney disease.

This qualitative, exploratory study examined the self-management experiences of people with mild to moderate chronic kidney disease (CKD, Stages 1-3) to elicit participants' perceptions of health, kidney disease, and supports needed for self-management. Findings revealed a process of renegotiating life with chronic kidney disease, which encompassed Discovering Kidney Disease and Learning To Live With Kidney Disease. A number of themes were identified including searching for evidence, realizing kidney disease is forever, managing the illness, taking care of the self and the need for disease-specific information. The findings indicate participants with early CKD want to self-manage their illness in collaboration with health care providers. As well, people with early CKD need guidance and support from health professionals to successfully self-manage. Nephrology nurses are uniquely positioned to provide this support while collaborating with other care providers to facilitate self-management.

The elusive goal of social integration: A critical examination of the socio-economic and psychosocial consequences experienced by homeless young people who obtain housing.

OBJECTIVES: The objective of this study was to provide an insider perspective on the experiences of nine formerly homeless young people as they transitioned into independent (market rent) housing and attempted to achieve meaningful social integration. METHODS: The study was conducted in Toronto, Canada, and guided by the conceptual framework developed for the World Health Organization by the Commission on Social Determinants of Health. A critical ethnographic methodology was used. Over the course of 10 months, the lead author met every other week with nine formerly homeless young people who had moved into their own homes within 30 days prior to study recruitment. RESULTS: Unaffordable housing, limited education, inadequate employment opportunities, poverty-level income, and limited social capital made it remarkably challenging for the young people to move forward. As the study progressed, the participants' ability to formulate long-range plans was impeded as they were forced to focus on day-to-day existence. Over time, living in a perpetual state of poverty led to feelings of "outsiderness," viewing life as a game of chance, and isolation. CONCLUSION: Rather than a secure, linear path from the streets to the mainstream, study participants were forced to take a precarious path full of structural gaps that left them stuck, spinning, and exhausted by the day-to-day struggle to meet basic needs. Despite their remarkable agency, it was almost impossible for the participants to achieve meaningful social integration given the structural inequities inherent in society. These observations have implications for practice, policy, and research.

Engaging street-involved youth using an evidence-based intervention: A preliminary report of findings.

PROBLEM: Street-involved youth experience many barriers to accessing health and social services. There is a literature gap in the literature regarding evidence-based interventions to facilitate engagement with street-involved youth. METHODS: A qualitative descriptive study of preliminary findings from a large mixed-methods study was undertaken to assess the impact of a resilience-based motivational intervention. This intervention was grounded in frameworks including strengths-based and resilience-based communication using the Seven C's Model of Resilience, positive youth development, and motivational interviewing that are particularly relevant to youth. Individual interviews were conducted with two subsets of youth who participated (n = 3) or did not participate (n = 3) in the intervention. Thematic analysis was conducted to identify themes between the intervention and comparison groups. FINDINGS: Preliminary themes identified across the sample include (1) establishing a trusting relationship, (2) strengthening self-worth and resilience, (3) focusing on goals, and (4) perceiving a sense of hope and possibility. CONCLUSIONS: The themes identified the importance of positive relationships with care providers built upon a foundation of trust to engage youth to remain motivated and focused on their goals.

Mindfulness practice as a teaching-learning strategy in higher education: A qualitative exploratory pilot study.

BACKGROUND: Students in higher education are experiencing stress and anxiety, such that it impedes their academic success and personal wellbeing. Brief mindfulness meditation and lovingkindness meditation are two aspects of mindfulness practice that have the potential to decrease students' feelings of anxiety and stress, and increase their sense of wellbeing and capacity for compassion for self and for others. PURPOSE: To explore how undergraduate and graduate students experience brief instructor-guided mindfulness practice; specifically, on their feelings of stress and anxiety, and their sense of wellbeing. STUDY DESIGN: Qualitative exploratory pilot study. PARTICIPANTS AND SETTING: Fifty-two graduate and undergraduate students in different disciplines within a community services faculty of an urban university. METHODS: Brief (five-minute) instructor-guided mindfulness practices were offered over eight weeks at the beginning and end of classes. Participating students were asked to also engage in individual home practice of five to fifteen-minute mindful breathing four to five times a week and to keep a log of their experiences. At end of term, individual and group feedback (N=13) was elicited from participating students. Six of the seven instructors who guided the mindfulness practices shared their experiences of the mindfulness activities. OUTCOMES: Students reported an increased sense of calm, and a decreased feeling of anxiety. Lovingkindness meditation was mostly perceived as a positive way to close the class. Their instructors also observed that the brief mindful breathing practice at start of class helped students become more grounded and focused before engaging in the course content. Challenges encountered focused on the need to provide more in-depth information about mindfulness, as it relates to higher education teaching-learning contexts, to both students and participating instructors. CONCLUSIONS: Implications for education suggest further research that includes fuller experiential training of participating instructors, as well as provision of a more comprehensive background on mindfulness to students.

Strategies for moving beyond the illness in early schizophrenia and in chronic kidney disease.

Although the literature suggests that loss of self is a universal concern across chronic illnesses in general, little consideration has been given to loss of self across physical and mental illnesses. The authors compare loss of self in individuals with a mental illness (early schizophrenia) and in those with a physical illness (chronic kidney disease). In this secondary analysis, focus group data from 2 samples are examined for similarities and differences in the emergent themes. While striving to be my best self getting on with life was an overarching goal for both groups, the strategies for achieving it differed. The participants engaged in activities related to approaching the illness, accommodating, and connecting in order to strike a balance between the demands of the illness and non-illness aspects of their lives. The commonalities in the wish to be my best self that were found in both groups indicate that the wish to preserve a sense of self beyond the illness may not be illness-specific. The preliminary results of this secondary analysis suggest that building a positive sense of self in the face of illness is a critical part of illness adjustment and that there are opportunities for nurses and researchers to learn about the spectrum of strategies employed by individuals as they strive to move beyond the illness.