Providing Gender Sensitive and Responsive Trauma-Informed Psychiatric Nursing Care. How Hard Can It Be?

This paper addresses the challenge of providing gender sensitive and responsive trauma-informed care (TIC) in psychiatric nursing practice. Gender identity, gender subordination, and gender-related trauma history are examined as three key individual-level factors that affect nurses' capacity to engage therapeutically to provide gender sensitive and responsive TIC. Using Peplau's Interpersonal Theory and building on a shared trauma and resilience model, gender-sensitive and responsive TIC is situated within interpersonal science and the ability of the psychiatric nurse to attune to her own and her patient's gender ideologies. Strategies for transforming practice including self-reflection, self-compassion, and peer and supervisor support are reviewed. Noting the import of the practice environment, several observations of changes needed at the level of the unit, organization, and society to effect gender equitable policies that enable the implementation of gender-sensitive and responsive TIC are made.

Self-Care Capacity and Its Relationship to Age, Disability, and Perceived Well-Being in Medicare Beneficiaries.

BACKGROUND: Self-care is a multicomponent set of capacities that influence beliefs about health and well-being. OBJECTIVES: We examined the relationship between self-care capacity, age, and disability status with two perceptions of well-being in a cohort of Medicare beneficiaries. METHODS: The current study is part of a multisite research project to determine factors associated with cross-sectional and longitudinal morbidity and mortality trajectories observed in Medicare beneficiaries. Variable selection was informed by the health disparities and outcomes model. Using data from the 2013 Medicare Current Beneficiary Survey and logistic regression models, we determined associations between self-care capacity, including indicators of self-care ability and self-care agency and two perceptions of well-being. Participants were divided into four groups based on how they qualified for Medicare: (a) over 65 years of age, and below 65 years of age and disabled because of (b) physical or (c) mental disorder, or (d) disabled and could not be classified as physically or mentally disabled as the primary cause of eligibility. RESULTS: Self-care ability limitations in activities of daily living (ADL), instrumental activities of living (IADL), and social activity participation were associated with both health perceptions. Those with physical disabilities reported more ADL and IADL limitations when compared with the other eligibility groups and were significantly more likely to have negative health perceptions. Those with serious mental illness were most likely to report the most severe IADL limitations. The over 65 years of age group reported less self-care incapacity than the other three eligibility types. Other components of self-care, including health literacy, agency, and health behaviors, significantly influenced perceptions of health. Women and people identifying as non-Whites were more likely to have negative health perceptions. DISCUSSION: Self-care capacity is a complex construct, and its varied elements have differential relationships with perceptions of well-being. Those with physical disabilities reported more self-care limitations, poorer perceived health, and more health worries than the other groups. Still, there were different patterns of self-care capacities in the serious mental illness type-especially in IADL limitations. The study adds empirical evidence to previous research documenting inequities in health outcomes for women and non-Whites. Findings provide empirical support for the health disparities and outcomes model.

The contributory role of the family context in early childhood sleep health: A systematic review.

Sleep-wake regulation is established during early childhood and contributes to life-long health. The family context is critical to the development of child sleep-wake regulation. The primary aim of this systematic review was to elucidate family-level constructs (outside of bedtime parenting) that contribute to early childhood (age 0-5 years) sleep health. We identified empirical research articles that investigate these relationships through systematically searching PubMed, Web of Science, and PsycINFO databases. The transactional model of sleep-wake regulation guided the selection of family-level search terms, including socioeconomic status (SES), family structure, household chaos, marital, co-parenting, and social relationships. Sleep search terms included sleep problems, duration, timing, and variability. We searched sleep and family terms in combination with infant, toddler, or preschool developmental age. Sixteen studies satisfied criteria for inclusion. Results indicated that the presence of household chaos and poor quality marital relationships were directly associated with early childhood sleep problems and variable sleep timing. Higher marital satisfaction and the presence of household routines were positively associated with sleep duration. Several, but not all, studies showed an association between lower SES and poor child sleep health. There were no significant direct associations for family structure and limited findings for the role of perceived social support and co-parenting relationship quality. Overall, operationalization and measurement of family and sleep constructs varied across studies, decreasing our ability to make comparisons and draw robust conclusions. Future research should identify modifiable family-level factors that can be targeted, in addition to bedtime parenting, to improve sleep-wake regulation development.

Modeling Health Disparities and Outcomes in Disenfranchised Populations.

The Health Disparities and Outcomes (HDO) model originally created to explain the complexity of obtaining healthcare in rural settings has been revised and updated using emerging theoretical models of adversity and inequity and two decades of empirical work by the authors. With a strong orientation to explaining population-based health inequities, the HDO is applied to individuals with Serious Mental Illness (SMI), to explain their high rates of morbidity and mortality compared to the general population. Individual-, community-, and system-level factors that reflect an understanding of life-long risk, accrued hazards associated with multiple and intersecting disadvantages, and difficulty obtaining healthcare that meets accepted standards are described. The revised HDO can be applied to populations with disproportionate health challenges to identify multi-level factors that affect illness trajectory and overall health outcomes.

Mental health treatment seeking patterns and preferences of Appalachian women with depression.

This qualitative study explored social-cultural factors that shape treatment seeking behaviors among depressed rural, low-income women in Appalachia-a region with high rates of depression and a shortage of mental health services. Recent research shows that increasingly rural women are receiving some form of treatment and identifying their symptoms as depression. Using purposive sampling, investigators recruited 28 depressed low-income women living in Appalachian Kentucky and conducted semistructured interviews on participants' perceptions of depression and treatment seeking. Even in this sample of women with diverse treatment behaviors (half reported current treatment), participants expressed ambivalence about treatment and its potential to promote recovery. Participants stressed that poor treatment quality-not merely access-limited their engagement in treatment and at times reinforced their depression. While women acknowledged the stigma of depression, they indicated that their resistance to seek help for their depression was influenced by the expectation of women's self-reliance in the rural setting and the gendered taboo against negative thinking. Ambivalence and stigma led women to try to cope independently, resulting in further isolation. This study's findings reiterate the need for improved quality and increased availability of depression treatment in rural areas. In addition, culturally appropriate depression interventions must acknowledge rural cultural values of self-reliance and barriers to obtaining social support that lead many women to endure depression in isolation. (PsycINFO Database Record

Home health care nurse interactions with homebound geriatric patients with depression and disability.

Building therapeutic nurse-patient relationships is pivotal to the provision of optimum nurse care management for geriatric home health care (HHC) patients. However, little is known about which strategies most effectively treat older adult HHC patients with concomitant depression and disability. This qualitative descriptive study was conducted in two parts to explore the issue further. The first part involved interviews regarding HHC nurse perceptions of geriatric depression and disability care management. The second part, which is the focus of the current analysis, describes HHC nurses' use of care management and therapeutic during home visits. Observation of nurse-patient interactions involved 25 nurses home visits to HHC patients 60 and older who had depression and disability. Drawing on clinical knowledge and interpersonal skills, nurses built relationships and fostered trust. However, despite their disabilities to make these connections, multiple missed opportunities occurred for nurses to engage in more productive interactions. Four training components to support improvement of nurse-patient therapeutic relationships are described and recommended.

A model to develop nurse leaders for rural practice.

Rural health disparities are due in part to access barriers to health care providers. Nursing education has been extended into rural areas, yet a limited rural research and practice literature informs the content and delivery of these educational programs. The University Of Virginia School of Nursing through a grant from the Health Resources and Services Administration developed the Nursing Leadership in Rural Health Care (NLRHC) Program. The transformational nursing leadership in rural health care (TNLRHC) model guided the development of NLRHC program content and teaching methods. This article describes the TNLRHC model and how it has steered the integration of rural content into advanced practice nursing (APN) education. The capacity of the TNLRHC model for promoting innovation in APN education is described. Recommendations regarding the future development of APN education are presented.

Feasibility, acceptability, and effects of gentle Hatha yoga for women with major depression: findings from a randomized controlled mixed-methods study.

Major depressive disorder (MDD) is a common, debilitating chronic condition in the United States and worldwide. Particularly in women, depressive symptoms are often accompanied by high levels of stress and ruminations, or repetitive self-critical negative thinking. There is a research and clinical imperative to evaluate complementary therapies that are acceptable and feasible for women with depression and that target specific aspects of depression in women, such as ruminations. To begin to address this need, we conducted a randomized, controlled, mixed-methods community-based study comparing an 8-week yoga intervention with an attention-control activity in 27 women with MDD. After controlling for baseline stress, there was a decrease in depression over time in both the yoga group and the attention-control group, with the yoga group having a unique trend in decreased ruminations. Participants in the yoga group reported experiencing increased connectedness and gaining a coping strategy through yoga. The findings provide support for future large scale research to explore the effects of yoga for depressed women and the unique role of yoga in decreasing rumination.

The effects of rurality on mental and physical health.

The effects of rurality on physical and mental health are examined in analyses of a national dataset, the Community Tracking Survey, 2000-2001, that includes individual level observations from household interviews. We merge it with county level data reflecting community resources and use econometric methods to analyze this multi-level data. The statistical analysis of the impact of the choice of definition on outcomes and on the estimates and significance of explanatory variables in the model is presented using modern econometric methods, and differences in results for mental health and physical health are evaluated.

Race and ethnicity and rural mental health treatment.

OBJECTIVE: Research has shown that there is less use of mental health services in rural areas even when availability, accessibility, demographic, and need factors are controlled. This study examined mental health treatment disparities by determining treatment rates across different racial/ethnic groups. METHODS: Data from the first four panels of the Medical Expenditure Panel Survey (MEPS) were used for these analyses. The sample consisted of 36,288 respondents yielding 75,347 person-year observations. The Economic Research Service's Rural-Urban Continuum was used as a measure of rurality. RESULTS: Findings show that rural residence does little to contribute to existing treatment disparities for racial/ethnic minorities living in these areas. CONCLUSIONS: Findings suggest that characteristics of the rural environment may disadvantage all residents with respect to mental health treatment. In more populated areas where mental health services are more plentiful, complex racial and service system factors may play a greater role in evident ethnic/racial treatment disparities.

Electronic screening for mental health in rural primary care: implementation.

The goals of this study were to develop a computer-based electronic screening tool (eScreening) and determine the feasibility of implementing eScreening for rural users of primary care. This descriptive pilot adapted existing screening measures for depression and alcohol abuse to a portable computer-based format and examined the feasibility of its adoption and use. This was a three-step design using convenience samples for (1) a focus group with providers, (2) usability testing with selected rural patients using the computerized touch screen, and (3) implementing the touch screen platform with a small sample in primary care to determine feasibility. This paper reports on Phase III, which assessed consumer response to eScreening.

Electronic screening for mental health in rural primary care: feasibility and user testing.

Despite attention to prevention and screening for depression and alcohol use, Healthy People 2010 objectives continue to include goals to increase the detection of depression and decrease the rates of alcohol abuse. These problems remain significant. The overall goal of this study was to develop a computer-based electronic screening (eScreening) tool and determine the feasibility of implementing computer-based eScreening technology for rural visitors to a primary care clinic. The study called specifically for an electronic touch screen with voice prompts. This tool, called the eScreening tool, screens for alcohol abuse and depression among rural patients in a primary care setting. The screening was offered to rural adults who are not in acute distress and not at end of life, regardless of their stated reason for seeking medical care. Phase 1 of the pilot was used to determine the perceptions of nurses, other providers, and consumers regarding the acceptability and perceived usefulness of an eScreening tool. Phase 2 involved user testing of the eScreening tool. The longer term goals of the research program are to work with rural nurses to improve patient outcomes and develop interventions and for educational, consultation, and/or direct clinical care.

Building the rural mental health system: from De Facto system to quality care.

About 20% of Americans live in rural America, yet the rural mental health infrastructure has yet to be firmly established. This is due in part to a pervasive belief about the tranquility of rural places and the relatively stress-free environment that they produce. In this chapter an adaptation of the Rural De Facto Mental Health Systems Model produced by Fox and her associates at the Southeastern Rural Mental Health Research Center is presented and used to organize the scientific state of the field of rural mental health services research. As many nurses have stood at the forefront of that research, the research of several prominent rural mental health nurse researchers and the innovative research they have produced are reviewed. The chapter concludes with a discussion of research that is needed to move the science of rural mental health services research forward, as well as a discussion of policy initiatives that may be necessary to foster the development and implementation of that research agenda.

Pilot testing Okay With Asthma: an online asthma intervention for school-age children.

Asthma is the leading cause of missed school days despite advancements in asthma treatment. This may be, in part, due to a lack of understanding about asthma. Okay With Asthma, an online story with psychosocial management strategies for school-age children, was pilot tested to measure its effect on asthma knowledge and attitude. The online program delivers content about asthma through a digital story and story-writing program. Using a one-group pretest-posttest quasi-experimental design, 35 children with moderate to severe asthma completed a pretest measure of asthma knowledge and attitudes and then completed Okay With Asthma. At 1 week and 2 weeks after the intervention, the children completed the measures again. There were significant improvements in asthma knowledge scores at the 1- and 2-week evaluations and significant improvements in attitude scores 2 weeks after the program. Okay With Asthma specifically targets school-age children and teaches them how to use school resources and peers while managing their asthma.

Enhancing children's health through digital story.

Stories in all of their many forms, including books, plays, skits, movies, poems, and songs, appeal to individuals of all ages but especially the young. Children are easily engaged in stories, and today's generation of children, the millennium generation, demands interactive, multimedia-rich environments. Story as a teaching and learning technique is pervasive in the classroom but is infrequently used to promote health. Because of advancing technology, it is possible to create interactive digital storytelling programs that teach children health topics. Using digital storytelling in an interactive environment to promote health has not been tested, but there is empirical support for using story in health education and interactive technology to promote health. This article briefly reviews the literature and discusses how technology and storytelling can be joined to promote positive health outcomes.

Prevalence of major depressive episodes in rural women using primary care.

Women carry a disproportionate burden of depression in part because situational and other factors enhance their risk. Rural women may be at particular risk because of poverty and lack of treatment opportunities. For this study we investigated the rate of current major depressive episodes (MDE) in impoverished rural women seeking care in a community health center (CHC) in the rural South. We screened 982 women for MDE during a routine primary care visit: about half were positive for depressive symptoms. Of women positive at screening, 194 were then assessed for psychiatric disorder. A current MDE was observed in 14.3% of women screened for depression and 72.2% of women assessed for psychiatric disorder. Recognizing that neither of these percentages reflects the likely rate of MDE among the larger population of rural impoverished women, we used probability theory and binary logistic regression to estimate a depression rate that could be applied as one factor associated with unmet need in this population of women. We estimate that 44.3% of the population of women using the CHC had MDE. These findings underscore the need for mental health services in rural primary care, especially in facilities serving impoverished women.