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Heart failure, a condition predominantly affecting the elderly, represents an ever increasing clinical and financial burden for the NHS. Patients with symptomatic heart failure have a poor prognosis and a high degree of morbidity. Current research findings suggest that enhancement of self-care through education, optimisation of pharmacological therapy, exercise training, lifestyle modification and counselling improves patient outcomes and reduces hospitalization. Cardiac rehabilitation, a service that incorporates all the aforementioned components, has yet to be evaluated in heart failure management. Set in a district general hospital with a primary catchment area of 500,000 inhabitants, this study is among the first of its type in the U.K. The study evaluates the effects of a cardiac rehabilitation programme on a range of outcome measures: mortality, health related quality of life, functional change, health care utilisation and clinical status. The design is a randomised controlled trial, comparing cardiac rehabilitation to standard care. Two hundred patients (60 - 89 years, 66% male) were recruited from hospital clinics, wards, and general practice. Patients with NYHAII or in heart failure confirmed, by echocardiography, were randomly allocated to control or experimental groups. Both patient groups attended out patient appointments to see the specialist nurse and cardiologist every eight weeks. In addition, patients in the experimental group attended cardiac rehabilitation classes twice weekly for eight weeks, followed by weekly exercise sessions for 16 weeks. Intervention consisted of exercise prescription, education, dietetics, occupational therapy and psychosocial counselling. A selection of measures were used to collect data over six months: Minnesota Living with Heart Failure (MLHF), New York Heart Association (NYHA) functional classification, EuroQol (EQ-5D), the six-minute walk test, Borg's rating of perceived exertion (RPE), medication compliance monitored by ACE inhibition, routine biochemisty, prescribed medication, coronary risk factor status, medical records and patient diaries. Results show statistically significant improvements for the experimental group in comparison to control patients. Improvements were identified in health related quality of life, functional status, metrs walked and patient cost utility; a reduction in hospital admissions attributable to heart disease was evident. No statistical difference between patient groups was evident in mortality, contact with primary health care professionals, compliance and clinical status. The findings are discussed in terms of previous rehabilitation studies. In conclusion, this study describes the necessary infrastructure and provides an evidence base for implementing a successful multidisciplinary cardiac rehabilitation programme in a district general hospital.

This thesis explores the contrasting experience of the discharge of older people from hospital on a Care of the Elderly Unit and Medical/Surgical Unit in a District General Hospital in North Wales. It comprises both the results of a Fourth Generation evaluation (Guba and Lincoln, 1989) and the later development of a substantive grounded theory of the discharge process (Charmaz, 2000). Both elements of the thesis were informed by a constructivist approach to research and the presentation and style of the thesis reflects this orientation. Data were collected from all the main stakeholder groups (members of the multidisciplinary team, patients and carers, members of the primary health care team) using a variety of methods including semi-structured interviews, documentary analysis and periods of observation. These data were then fed into a series of hermeneutic cycles in an effort to reach consensus about desired change. Barriers to both consensus and change were identified and explored largely in terms of the threat they posed to traditional medical power bases. The subsequent theory suggested that the differences between the Units could be explained largely in terms of the orientations on the ward, one of which 'processed patients' with an emphasis on pace (speed of throughput) while the other 'processed people' with more recognition of the complex needs of older individuals. In both Units the role of the nurse was significant and comprised a number of key processes: pushing; fixing; informing and brokering. The ways in which these processes interact are considered and their impact on the discharge process described. The quality of the thesis is considered on a number of criteria and the extent to which the results can be recontextualised is addressed. Finally, implications for policy and practice in the light of recent developments are discussed.

This thesis examines the development of nursing at University College Hospital, London, between 1862, the year in which the All Saints Sisters assumed responsibility for the provision of nursing services at the hospital, and the introduction of the National Health Service in July 1948. Although the care provided by the sisters marked a considerable improvement on what had gone before, in 1899 they were replaced by nurses whose motivation was professional rather than vocational. The profession of nursing was confirmed by the Registration Act of 1919. Following an introduction, the initial chapters of the thesis are concerned with defining and developing the themes of Christian vocation and secular profession. Chapter four is devoted to nursing management across the period, and the following chapter to patterns of care. Prior to 1919 a system of primary care was in operation; this was superseded by task allocation. Chapters six and seven outline the introduction of nurse training in some of the London teaching hospitals in comparison to the training of nurses at U.C.H. An analysis of the probationer records from 1890 - 1948 demonstrates recruitment and retention through these years. With the departure of the All Saints Sisters from U.C.H. in 1899 the school of nursing was established. A preliminary training school was introduced in 1926; ten years later University College Hospital school of nursing pioneered the block system of training which became the norm for all schools of nursing after the Second World War. The next two chapters concentrate upon nursing developments in wartime. The All Saints Sisters were part of the British Red Cross team that served in the Franco-Prussian War of 1870 and the hospital and its nurses were fully involved in the two World Wars. Although this period saw the transformation of nursing at U.C.H. from a Christian vocation to a secular profession, this thesis is as much concerned with continuity as with change - for example in noting the similarities between rules for the probationers and for the novitiates, which had continuing influence throughout the years of this study.

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