This manuscript option dissertation elucidates the role of patient-provider interactions in keeping HIV positive Black women in medical care. Since 2012, the Arizona State Department of Health has acknowledged that women of African descent are disproportionately affected by HIV and die at higher rates from AIDS-related complications than other women. The dissertation includes three manuscripts covering a feature of this topic. The first paper is a scoping review of literature on what is known about the influence of patient-provider relationships on adherence and viral suppression among Black women living with HIV in Arizona. The second is an empirical study built upon interviews with Black women living with HIV analyzed through constructivist grounded theory to understand women’s perspectives of provider actions that keep them in care. The third offers practice recommendations based on the interviews with Black women living with HIV, dialog with HIV advocates, and proceedings of the Phoenix Fast Track Cities ad hoc committee to end HIV as an epidemic. Together, the three manuscripts integrate the voices of women, advocates, and past research to support best practices and future steps for HIV retention strategies.

The purpose of this study is to identify the needs of older adults with Alzheimer's disease (AD) and related dementias (ADRD) admitted to a rehabilitation setting where they are expected to physically and mentally function to their optimal level of health. To date, no studies have identified the needs and concerns of ADRD patients in rehabilitation settings. The Needs-Driven Dementia-Compromised Behavior (NDB) Model, the researcher's clinical experience, and the state of the current scientific literature will help guide the study. An exploratory qualitative research approach was employed to gather data and discover new information about the ADRD patient's needs and related behavioral outcomes. The qualitative findings on the discrepancies and similarities in perceptions of ADRD patient needs were obtained by examining formal and informal caregivers' perceptions. The researcher recruited registered nurses and certified nurse assistants (RNs and CNAs, formal) and family/friends (informal) who have provided care to patients in inpatient rehabilitation facilities to participate in focus groups and individualized focused interviews. The data were collated and analyzed using a thematic analysis approach. The overarching theme that developed as a result of this approach revealed discordant perceptions and expectations of ADRD patients' needs between the formal and informal caregivers with six subthemes: communication and information, family involvement, rehabilitation nurse philosophy, nursing care, belonging, and patient outcomes. The researcher provided recommendations to help support these needs. These findings will help guide the development of nurse-lead interventions for ADRD patients in a rehabilitation setting.

The treatment of individuals with multiple chronic conditions represents the single largest driver of Medicare costs. The use of prescription drugs is a major component in the treatment/management of chronic disease in the United States. Medication nonadherence, however, is a common problem among older adults and leads to significant morbidity and mortality. Whereas, the problem of medication nonadherence has been a primary focus of research for the last thirty years, much is still unknown about which older adults are most at risk for medication nonadherence, as well as what are effective theory-based interventions to improve a person's medication self-management.

The purpose of this descriptive explanatory study was to better understand the self-management behavior, medication adherence, in a sample of frail urban older adults. The study used a combination of quantitative and qualitative methods to analyze data from a larger twelve-month study of a nurse care coordination intervention. Ryan and Sawin's (2009) Individual and Family Self-Management Theory served as the study's conceptual framework for identifying the context and processes involved in the older adults' medication self-management. Quantitative results found several individual- as well as family-level predictors for medication nonadherence. Qualitative analyses identified three overarching themes to describe the participants' struggles along the multistep process of medication adherence. Additionally, a cultural domain described the need for more information from participants to understand their nonadherence. Integration of the results further increased our understanding of medication-self management in these frail older adults, and offers direction for clinical practice and future research.

ABSTRACT Caregiving studies generally do not focus on the post-caregiving phase of care, or African Americans post-caregivers (AAPCGs). This mixed-methods study guided by the Transitions Theory, explored the experiences of 40 AAPCGs residing in Los Angeles, California and Phoenix, Arizona, whose loved ones died within the last 10 years. Data collection tools included individual interviews, demographic questionnaire, CES-D, Brief Cope, and Social Support. Findings present the specific aims of the study. Aim 1 dealt with the types, patterns and properties of post-caregiving transitions (PCT). Many AAPCGs experienced multiple, simultaneous transitions that continued to impact their lives many years after caregiving ends. Aim 2 dealt with factors that facilitate or inhibit healthy PCT. Facilitators include: Being satisfied with care provided; fulfilling death-bed promises; living out the legacy of the deceased; deep spiritual beliefs in God and support of family, friends and church. Inhibitors include: Experiencing a deep sense of loss, confusion, depression, loneliness, and guilt; physical challenges such as fatigue and exhaustion, breathing problems, dizziness, fainting, cognitive difficulties, pain, headaches, hypertension and insomnia; family conflicts, job or home loss that linger long after PCT. Aim 3 involves process indicators including: connectedness with family, friends, co-workers, church and God; returning to work or school. Coping strategies that helped AAPCGs include: productive ventures, family mementoes, reminiscing, new baby, or visiting cemetery. Appropriate coping led to outcome indicators of mastery such as new environment; making decisions; taking actions; readying oneself for another caregiving role; preparing for one's own life and death; or caring for self. Fluid integrative identities include: Sense of balance, peacefulness and joy, fulfillment, compassion; remembering without pain; or new identity. Implications for practice, policy, education and research include: Care providers and policy makers must ensure that AA caregivers receive adequate EOL and hospice information and support for adequate preparation of loved one's death. Geriatric educators must design and implement curricular programming that includes the post-caregiving phase as a very important phase of caregiving. Researchers should design culturally-congruent assessment tools or improve the checklist developed in this study to appropriately measure PCT; and also develop culturally-relevant interventions to facilitate healthy PCT.

Spousal bereavement is one of the most stressful life events, resulting in increased morbidities and mortality risk. Negative health outcomes include depressive episodes, anxiety, sleep disruption, and overall poorer physical health. The older adult population is rapidly increasing and over 30% of the US population 65 years and older are widowed. Current studies regarding older adults and spousal bereavement treatment have been limited to psychological and educational interventions. Meditative movement practices (e.g. Tai Chi) have shown benefits such as mood elevation, anxiety reduction, and other physical function improvements. A feasibility study applying an 8-week Tai Chi Easy intervention was examined to address the sequelae of spousal bereavement among adults 65 and older. Grounded in geriatric nursing as a discipline that addresses the unique needs of older adults' psychological and physiological health needs and related theoretical constructs, this project also draws from exercise science, mental health, and social psychology. Theoretical premises include Orem's Self Care Deficit Theory (nursing), Stroebe and Schut's Dual Process Model (thanatology), and Peter Salmon's Unifying Theory (exercise). Aims of the study examined feasibility as well as pre-post-intervention changes in grief, and the degree of loss orientation relative to restoration orientation (Inventory of Daily Widowed Life). A trend in the direction of improvement was found in measured subscales, as well as a statistically significant change within the loss orientation subscale. Based upon these encouraging findings, effect sizes may be used to power a future larger study of similar nature.

While the literature on caregivers of loved ones with Alzheimer's Disease and Related Disorders (ADRD) has continued to grow, the relationship of ethnicity and acculturation factors with regards to the coping strategies used by caregivers has not been extensively explored. The current study included participants from the Palo Alto site of the Resources for Enhancing Alzheimer's Caregiver Health (REACH) project. The study examined differences in coping strategies between 140 non-Hispanic White, 45 less acculturated Latina, and 61 more acculturated Latina caregivers. Univariate and Multivariate Analysis of Variance, as well as post hoc analyses, were conducted to determine the differences among the three groups. Results indicated less acculturated Latina caregivers employ more avoidant coping strategies compared to non-Hispanic White caregivers. However, no differences were found among the other groups in their use of avoidance coping. Moreover, there were no differences found in the use of social support seeking, count your blessings, problem focused, and blaming others coping among the three groups. These findings have important implications for the design of culturally relevant psychoeducational and therapeutic interventions aimed towards meeting the individual needs of these three populations. In addition, the findings expand on the understanding of maladaptive coping strategies that may be potentially exacerbating caregiver distress among Latina caregivers.

Multicultural counseling competencies (MCCs) are fundamental to the ethical practice of providing services to clients. One such competency is the aspect of self-awareness of one's own worldview. As such, it is incumbent that attention to counselor's self-awareness be a part of clinical training. While research has begun to examine multicultural supervision, much of the research holds assumptions about the types of multicultural discussions that take place, as well as what may actually occur within these sessions. Little is known about what is discussed and how. This exploratory, qualitative study examined what actually occurs within clinical supervision sessions with regard to having discussion of multicultural perspectives, as well as how supervisors and supervisees experience these discussions. Five supervisory dyads from university counseling centers in the southwest were recruited to engage in a guided discussion of multicultural perspectives (DMP) in a supplemental supervision session. In these DMPs, dyads were asked to discuss issues related to personal identity, as well as to discuss the relevance of having such discussions in clinical supervision. Both the supervisors and supervisees then engaged in follow-up telephone interviews with the researcher to discuss their experience in having this discussion. All supervision sessions and follow-up interviews were recorded and transcribed. Grounded theory was used to analyze the transcribed sessions and the follow-up interviews for emergent themes. Four domains emerged from the data: dynamics in the relationship, cultural lens, characteristics of the discussion, and impact of the discussion. Further, several areas of congruence between supervisors' and interns' accounts of what occurred during the DMP, as well as congruence between supervisors' and interns' accounts of what occurred and what actually happened during the DMPs were discovered. These areas of congruence that emerged included power, similarities, differences, comfort level, enjoyment, intentionality for future work and increased awareness. The one distinct pattern of incongruence that emerged from the data was in the category of increased connection in supervisory relationship. A theoretical model of supervisors' and interns' experiences in discussions of multicultural perspectives is included. Implications, limitations and suggestions for future research are explored.