Thesis advisor: Karen S. Lyons / OBJECTIVES: Individuals with severe persistent mental illness (SPMI), also referred to as serious mental illness (SMI), experience significant inequities in health care access and outcomes. These inequities may span the lifetime of an individual living with SPMI, and include poorer cancer outcomes, shorter lifespans, barriers to having their needs met in long-term care, and a decreased likelihood of receiving hospice care when indicated. The purpose of this dissertation was to explore the causes of the disproportionately poor health outcomes for individuals living with SPMI and describe current facilitators and barriers to providing care to this vulnerable population. METHODS: A qualitative descriptive study was carried out to explore health care professionals’ perception of the needs of long-term care residents with SPMI and chronic medical conditions. and barriers and facilitators to meeting the needs of this population. A narrative review was performed to identify what is currently known about cancer symptom clusters in individuals with schizophrenia. Lastly, an integrated review was conducted to identity factors associated with hospice use by individuals with SPMI and potential barriers to use of hospice services. RESULTS: Ten health care professionals were interviewed for the qualitative study. The themes that emerged were: coming to know the individual and their unique needs takes time; being flexible and adapting approaches facilitates trust; respecting the inherent worth of each person contributes to caring. Participants described the importance of a person-centered approach when caring for long-term care residents with SPMI and chronic medical conditions. The narrative review of current literature pertaining to cancer symptom clusters in individuals with schizophrenia revealed that this phenomenon has been sparsely represented in research. No data directly pertaining to cancer symptom clusters in this population were identified. Data describing the related phenomena of health conditions that may influence cancer risk and outcomes, physical experiences of cancer, and emotional and behavioral symptoms which may impact ability to tolerate cancer treatments were identified. The integrated review of literature describing factors associated with hospice use among individuals with SPMI found that hospice and palliative care services may not be utilized by individuals with SPMI due to system-level barriers such as inadequate patient-provider communication, fragmented care, and absence of discussions around end-of-life care. CONCLUSIONS: Systemic problems such as miscommunication, fragmentation of care, and stigma contribute to the health inequities experienced by individuals living with SPMI. Nurses and other health care providers can work to ameliorate these systemic problems by promoting and participating in collaborative care models and utilizing assessment techniques appropriate to individuals who may have difficulty communicating about their health-related symptoms. Individuals with SPMI should be offered opportunities to participate in research when appropriate so that they may benefit from newer treatments for disease, and health care providers may improve their understanding of how to address the medical needs of this population. / Thesis (PhD) — Boston College, 2022. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

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In Ontario, the majority of children and youth with mental illnesses access primary care as their initial source of mental health services (Institute for Clinical Evaluative Sciences, 2017). Primary care can be an ideal setting for accessing mental health services to prevent symptoms from worsening (Cappelli & Leon, 2017). Adolescence is a time when young people experience several developmental changes and transitions, making them susceptible to mental illnesses (Government of Canada, 2011). Examining adolescents’ perceptions of access is critical to examining how primary care is accommodating their mental health needs (Cappelli & Leon, 2017). The primary purpose of this study was to explore the perceptions of adolescents, living in Hamilton, Ontario, with an anxiety or mood disorder, of accessing primary care for mental health services. Perceptions regarding the role of primary care nurses in facilitating access was also explored. Qualitative interpretive descriptive methods were utilized. Data collection included: demographic survey, semi-structured interviews, photo-elicitation project, field notes, and reflexive journaling. Analysis was guided by an access framework (Penchansky & Thomas, 1981) and ecological model (McLeroy et al., 1988). Adolescents ages 15 to 18 years (n=10) participated. Adolescents perceived access to primary care for mental health services as a difficult and complex process involving multiple stages including: feeling uncertain about their mental health concerns and if they required help, seeking informal support from parents and friends to initiate receiving help, and obtaining mental health services from primary care. Implications of this study include addressing adolescents’ developmental needs in care through implementing an individualized-approach and supporting development throughout emerging adulthood. Primary care practitioners must provide information to adolescents and parents about mental health concerns and services during routine interactions. Greater organizational support would enable primary care nurses to have an active role in delivering mental health services and providing comprehensive care. / Thesis / Master of Science in Nursing (MSN)

In contemporary societies, such as Canada, the United Kingdom and the United States, an emphasis has been placed on moving individuals with mental illness into mainstream paid employment. Although mainstream employment may offer an inclusive environment, existing scholars argue that various problems can arise with this transition to paid work. For example, employers often report a minimal understanding regarding accommodations for someone with mental health issues and workers may be reluctant to disclose mental health issues for fear of workplace discrimination and/or discharge. Social enterprises have been created to address these problems and the available literature illustrates that these organizations are beneficial for individuals with mental illness because they offer necessary workplace accommodations that are often not found in mainstream jobs, allow for engagement in meaningful activity and provide the opportunity to earn a wage. However, scholars have primarily relied on secondary sources and/or surveys of these organizations and, as a result, there is a limited understanding of how social enterprise organizations work in practice. This thesis research seeks to address this gap by using participant observation, along with semi-structured interviews and focus group data, to produce an in-depth analysis that examines the daily operations of a social enterprise in Ontario, Canada, and the experiences of the workers within it. Key themes of analysis pertain to the nature of the work and the labour process; workers’ wages; the organization as a place for meaningful activity and social interaction; and the provision of workplace accommodations. The findings that have emerged from this project have empirical, methodological and conceptual contributions to the existing work on social enterprises for individuals with mental illness. / Thesis / Master of Arts (MA)

The collection of short stories presented in this thesis seeks to form a counter-narrative to the stigmas associated with mental illness and trauma through the portrayal of protagonists suffering from or affected by such issues. Individuals influenced by mental illness and/or trauma are not "others" deserving ostracization but fellow human beings searching for hope in a world too often touched by sorrow. The first three stories within this thesis address protagonists directly impacted by mental illness. "Twin Magnolias" follows Maggie Briggins, an elderly woman battling both paranoia and Alzheimer's simultaneously in a search for reality. "Fabergé" explores Candy Friedman's depression and relationship to her past as a ballerina. In "A Few Flowers to Hold," Leo Berns finds closure from a past filled with trauma and guilt through the connections his schizophrenia provides him. In contrast, the final two stories depict the lives of protagonists indirectly affected by mental illness. After the stillbirth of his daughter, Richard Glim finds hope in an unlikely place, a nursing home. Finally, the title piece of the collection explores and compares differing views of caregiving through the lives of Maggie Briggins' daughter and granddaughter. These perspectives demonstrate that mental illness and/or trauma are not what define a person but are simply a part of their lives. The number of individuals seeking help with mental health issues and trauma, especially among the younger generations, seems to be skyrocketing. Therefore, a larger body of literature that deals with such topics in a respectful and humanizing way is needed if our culture is to lovingly embrace individuals whose lives have been changed by these issues.