This study examines health professional work in intensive care units (ICUs) aiming to draw out the associated interplay of context-specific factors and social processes through which clinicians accomplish their day-to-day practice. The study was conducted against a backdrop of political and public pressure for safe, quality and efficient healthcare, in which inter-professional work was argued as key to containing these challenges. The study has been theoretically informed by an interactionist perspective to the division of labour and has followed an ethnographic approach. Data have been collected through fieldwork in three London ICUs employing observation of actual and in situ practice complemented by interviews with health professionals. Findings indicated that in response to the critical and fluctuating nature of patients’ conditions in ICUs, day-to-day health professional work was organised in dynamic terms, in which professional jurisdictions were shared and disputed, influenced by professional care priorities, staff seniority and work urgency. Differing professional priorities regarding patient care posed a challenge to conventional professional boundaries, giving rise to inter-professional disputes. These were managed through interaction as they arose in day-to-day practice. Senior staff made confident claims over aspects of work and utilised direct communication approaches while junior staff evaded overt confrontation. Under conditions of intense urgent work, where patient deterioration was rapid and the potential for death was high, jurisdiction concerns appeared suspended as professionals coordinated their work through non-verbal and highly attuned interaction. Considered together, these findings indicate that health professional work in ICU operates within an intricate system of professions which is influenced by wider health policies and context-specific clinical exigencies, is prone to disputes over jurisdictions, and is accomplished through day-to-day discursive and tacit interaction. Through this study a deeper insight into health professional work in ICU is gained that can inform the development of more refined and resilient health policies. Understanding the ways in which health professional work is organised and delivered in ICU will help to equip clinicians with the insight required to shape the future of this service towards the provision of safe and high-quality healthcare.

Intermediate care (IC) describes services which are targeted at older adults and aim to prevent unnecessary hospital admission, promote faster recovery from illness, support timely discharge and maximise independent living. The aim of the research presented in this thesis was to explore various aspects of medicines management relating to IC facilities, including how medicines are managed by staff and patients, communication between IC facilities and other healthcare settings, pharmacy involvement with IC, and the appropriateness of prescribing amongst the population that IC services cater for. Both qualitative and quantitative methodology was used throughout the five studies contained in this thesis. Various challenges relating to how medicines are prescribed, supplied and reviewed within IC were described. Despite an evident need, there was a distinct lack of pharmacy input within IC. Community pharmacists had limited awareness of and involvement with their local IC services and viewed communication relating to patients’ medications as inconsistent when patients moved across the various healthcare interfaces. Furthermore, cases of potentially inappropriate prescribing (PIP) were found in significant proportions of older patients at both admission to and discharge from IC. Similarly, PIP was found to be highly prevalent amongst older adults at discharge from secondary care, where deficits in the communication across the healthcare interface were also noted. The work contained in this thesis has highlighted various deficits in how medicines are managed in this patient population, both in the IC setting and beyond. Whilst there appears to be a mismatch between the concept of IC and the reality of services provided, appropriate management of medicines is a fundamental component of care for the patient population targeted by such services and requires further attention. Defining and evaluating how pharmacists can effectively integrate with IC services should form the focus of future work in this area.

In 2008 the National End of Life Care Strategy was released in England to create a largescale change in the way dying patients were cared for. This dissertation explores the meaning, practice, and experiences of end-of-life care (EOLC). It is based on ethnographic fieldwork from 2010-2012 that follows policy into and across healthcare practice and the daily lives of those living with life-limiting conditions. The first part of the study analyses the discourse of policy as evident in documents, policy events, and interviews with policy-makers, to understand the core values and motivations within this new field. By emphasising patient choice through advance care planning as a way to facilitate a ‘good death’, these polices have reshaped how persons, as dying patients, could be known and how they are positioned within the healthcare system as autonomous, reflective individuals. Documents like the Preferred Priorities for Care are used to facilitate this process. As observed during clinical visits and expressed in interviews, healthcare professionals selectively use such forms, thereby demonstrating varying professional values, and treat their completion as a task. The layout and use of the forms influences professional-patient interaction and the ‘choices’ that can be made. The second half of the dissertation focuses on the experiences of those who are the subject of EOLC policy and is based on long-term interaction with 10 people (up to 14 months), often in their own homes and involving their daily routines and family; this is supplemented by an additional 43 in-depth interviews and observations of support groups. Being embedded in a social web of relations was a prominent feature of our encounters. Maintaining familial relationships and roles is important to people and they do this by navigating the flow of care and concern within the family. Assumptions about the linear trajectory of dying and the finitude of death are challenged by people’s experiences of prolonged waiting and incomplete endings as they continued to be entangled in social relationships. Consequently a wider notion of personhood beyond individual patienthood should be adopted for understanding living at the ‘end of life’. Shifting the focus from choice as an individual act and object to one of interaction, I demonstrate how a relational approach to the study of end-of-life care challenges the emphasis on the dying individual and the dichotomy between care and choice. Overall, this ethnography demonstrates the difference between how policy conceptualises end of life and choice and the way people, who may be in this category, experience living with life-limiting conditions.

This thesis deals with the concept and practice of truth-telling in medical settings. In particular, it analyses the way in which truth-telling is enacted in the context of end of life care in Japan. The thesis addresses not only the content of what is communicated in encounters between physicians and medical personnel with patients and their family carers (next of kin), it also discusses the way in which information concerning diagnosis, treatment, and prognosis is communicated. That is to say, in the quality and integrity of the encounter. The thesis offers a literature survey of research studies that address truth-telling in medical settings in the USA, the UK, and in Japan, offering a comprehensive survey of studies written in English and Japanese. It investigates the history of the concept and practice of truth-telling in medicine from the turn of the twentieth-century to the present day, and it connects this history to the developing field of medical ethics. Over the course of this history one can identify a shift – especially in the West – away from medical paternalism towards patient-centered medical care, in which patient autonomy and self-determination are highly valued. This has influenced the understanding and practice of truth-telling in medicine. Japan, however, has preserved certain cultural values, traditions, and conventions that affect medical practice. The thesis analyses the effect of these behavioural norms on truth-telling practices in end of life care in Japan. It is argued that the hierarchical society, strong family structure, paternalistic culture, and conversational etiquette of Japan tend to stymie effective communication and limit truth-telling concerning diagnosis, treatment, and prognosis in medical settings. In light of the findings of the literature survey, the thesis proposes some concrete ways to promote truth-telling and effective communication in medical settings, including through the building of trust between interlocutors and through the reflective praxis of critical and creative contemplation.

The presentation of information is central to decisions to engage in a treatment and the uptake of health care behaviours. Hence understanding the processes which are responsible for framing effects within the health domain is crucial to achieving effective and unbiased communication. Within the message framing literature decision making is considered being a function of the valence of the information which is presented. Research has shown that individuals are more likely to attend a screening examination when information is presented as a loss a frame and more likely to engage in preventative behaviour when information is presented as a gain frame. However according to Rothman and Salovey (1997); Rothman, Kelly, Hertel, and Salovey (2003) it is the degree to which performing a health behaviour presents risk to the individual that determines whether a positively or negatively valenced version of information is more likely to be effective in encouraging the behaviour advocated. To date, studies assessing the hypothesis by Rothman and Salovey (1997); Rothman et al (2003) have only considered framing effects in the case of decision making for the self, and have not considered how framing of information may influence choice tasks. Additionally emotional reactions to risk information may play a part in determining the influence of framing effects (Lowe and Ferguson, 2003). The first experiment explored the acceptance of a blood transfusion for the self and on the behalf of a family member and friend within the frameworks of Rothman and Salovey (1997). In relation to this, the risk – as - feelings hypothesis by Lowenstein, Weber, Hsee, and Welch (2001) which postulates a direct effect of feelings onto choice, was examined. In the second chapter a standardised(word study changed to chapter as this not an experiment and so it is correct not to call as such chapter) instrument to measure factors around which people decide to accept blood transfusion products was developed. The final two experiments tested the two hypotheses in relation to a choice task and under a time constraint. Under a time constraint the potential for cognitive processes to play a role in decision making is reduced and the role of hot cognitions (emotions) is heightened. Hence the last experiment aimed to expose the role that affect may contribute to message framing effects by investigating whether the same framing effects could be observed when choosing between two blood transfusion products with and without a time constraint. When making a decision on the behalf of the self, a family member and a friend to accept a blood transfusion or to choose between two blood transfusion types a gain frame effect was observed. The framing effect did not alter under a time constraint in the case of decision making on the behalf of any potential recipient. Investigations of affect (trait, anticipated and immediate emotion) and cognitive motivational factors important to decision making as potential mediators produced null results. However, direct effects of immediate emotion were observed when decision making was for the self, family member and a friend in the first experiment and in the case of the self in Experiment 3. The findings obtained lend support to the increasing call for both cognitive and emotive processes to be incorporated into models of decision making, and to the argument by Rothman and Salovey (1997) that the function of the treatment under consideration moderates framing effects. The blood transfusion service gains valuable information on the importance of psychological factors to aid in planning public information campaigns.

<b>Background</b> The term patient-centred care (PCC) is commonly used in the academic literature and UK health policy. However, this concept is ill defined and little is known about its applicability to the management of people with long-term conditions (LTCs). Several methodologies were used to explore the meaning of PCC, identify key experiences that matter to people with LTCs and consider the implications of these findings for the measurement of patient reported experiences of health care. <b>Method</b> Four stages of research were conducted for this thesis. First, a conceptual synthesis of existing PCC and patient experience frameworks to produce an overarching framework of PCC. Second, secondary qualitative analysis of patient interviews to identify key experiences of PCC that matter to people with LTCs. Third, development of a PCC questionnaire for people with LTCs, based on findings from the conceptual synthesis and secondary analysis. Fourth, further exploration of the questionnaire through cognitive debriefing interviews with people with LTCs and health professionals. <b>Results</b> The overarching framework of PCC consisted of 8 domains; access, availability and choice, information, communication and education, relationship with health professionals, involvement in care, respect and dignity, responsiveness to individual needs and preferences, consistency, continuity and co-ordination, and effectiveness of treatment and care. Findings from secondary analysis suggested that many of the domains from the framework were also important in care for people with LTCs, but that some aspects of care held an additional meaning. The themes identified in the secondary analysis were used to generate items for a generic PCC experience questionnaire for people with LTCs. The final questionnaire, ‘Your Experiences of Care in Long-Term Conditions’ consisted of 47 questions across three sections. Feedback from the debriefing interviews suggested that the questionnaire had asked important questions about care for people with LTCs and that it was relevant to people with a range of different LTCs. <b>Conclusion</b> Development of an overarching framework of PCC demonstrated some conceptual problems in understanding and evaluating the notion of PCC. Findings from this thesis suggest that an overarching questionnaire of experiences of PCC is feasible and acceptable to people with a range of different LTCs. Future research needs examine standard features of the newly developed PCC experience questionnaire for people with LTCs and consider the potential use and contribution of data in enhancing care for people with LTCs.

Locum community pharmacists (‘locums’) constitute a significant proportion of the community pharmacy workforce in the UK, and have been identified as isolated practitioners who work outside existing quality assurance processes. This study examines professional engagement of locums in terms of their networking with pharmacist colleagues and their professional identity as pharmacists. With a constructivist, inductive approach, the study consisted of a series of five focus groups with a total of 25 participants in 2013, which were thematically analysed to yield a series of themes around professional engagement. The focus groups confirmed the isolation felt by locums and the effort undertaken by them to develop and maintain networks with colleagues. Locums used their networks for obtaining information, benchmarking their practice, decreasing personal stress, problem solving, sharing opinion on moral and ethical issues and promoting professional growth Next, the LocumVoice online forum for locum pharmacists was observed for a two month period in 2014, with the data being examined using an adaptation of Bales’ interaction process analysis, integrated with thematic analysis of the content. The interactions and content of the forum support it being considered a pharmacy community of practice, with locums’ interactions developing professional identity concepts via storytelling, sharing opinions and information. In particular, views on the nature of the role of the pharmacist were prominent in the discussions. The study contributes to knowledge of UK locum community pharmacists in that it describes the purpose and value of networking as perceived by locums and examines in detail the interactions occurring on an online community of practice that contribute to locum professional engagement and identity development.

The analysis of volatile organic compounds (VOCs) in breath may be a useful non-invasive tool in the Intensive Care Unit (ICU) to monitor metabolic and oxidative stress or diagnose pulmonary infection. Acetone is produced during starvation and metabolic stress, hydrogen sulphide (H2S) may be a marker of inflammation and infection and hydrogen cyanide (HCN) may also act as a marker of infection, particularly caused by Pseudomonas aeruginosa. Firstly, the effects on measured VOC concentrations of the breath collection equipment and storage were assessed. Sample humidity declined faster than any analyte. Sample losses of 21%, 25% and 24% for acetone, H2S and HCN, respectively, were seen as a result of being passed through the sampling apparatus. Over 90% of initial breath VOC concentrations were detectable after 90 min storage in Tedlar bags at 40°C. Secondly, a breath collection method for off-line analysis was validated in 20 mechanically ventilated patients in the ICU. The effect on VOC concentrations of breath sampling from two locations after two breathing manoeuvres was explored, revealing significantly higher analyte concentrations in samples from the airways than from a T-piece in the breathing circuit, and after tidal breathing compared to a recruitment-style breath. Practical difficulties were encountered using direct airway sampling and delivering recruitment style breaths; end-tidal breath sampling from the T-piece was simplest to perform and results equally reproducible. Breath samples from 26 healthy anaesthetised controls were used to validate a breath collection method in the operating theatre. The effects of altering anaesthesia machine settings on inspiratory and exhaled acetone concentrations were explored. A difference in median inspiratory, but not exhaled, acetone concentrations was observed between the anaesthesia machines (ADU Carestation 276 ppb, Aysis Carestation 131 ppb, p=0.0005). Closing the adjustable pressure limiting (APL) valve resulted in a reduction in exhaled acetone concentration, as did breath sampling distal to the circuit filter, due to dilution by dead space air. Median (range) breath concentrations for samples collected on the patient side of the circuit filter with the APL valve open (n=22): acetone 738 ppb (257–6594 ppb), H2S 1.00 ppb (0.71-2.49 ppb), HCN 0.82 ppb (0.60-1.51 ppb). Breath acetone concentration was related to plasma acetone (rs=0.80, p<0.0001) and beta-hydroxybutyrate concentrations (rs=0.55, p=0.0075). Finally, breath and blood samples were collected daily from 32 mechanically ventilated patients in the ICU with stress hyperglycaemia (n=11) and/or new pulmonary infiltrates on chest radiograph (n=28). Samples were collected over a median 3 days (1-8 days). Median (range) breath VOC concentrations of all samples collected: acetone 853 ppb (162–11,375 ppb), H2S 0.96 ppb (0.22-5.12 ppb), HCN 0.76 ppb (0.31-11.5 ppb). Median initial breath acetone concentration was higher than in anaesthetised controls (1451 ppb versus 812 ppb; p=0.038). There was a trend towards a reduction in breath acetone concentration over time. Relationships were seen between breath acetone and arterial acetone (rs=0.64, p<0.0001) and beta-hydroxybutyrate (rs=0.52, p<0.0001) concentrations. Several patients remained ketotic despite insulin therapy and normal, or near normal, arterial glucose concentrations. Inspired and exhaled H2S and HCN concentrations were not significantly different. Breath H2S and HCN concentrations could not be used to differentiate between patients with pneumonia and those with pulmonary infiltrates due to other conditions. In conclusion, losses due to the sampling apparatus were determined and linear over the range of concentrations tested. End-tidal breath sampling via the T-piece was the simplest technique, with reproducibility comparable to other methods. It was possible to replicate the breath sampling method in the operating theatre; pre-filter samples with inspiratory gas flow rate 6 L/min and APL valve open provided repeatable results avoiding rebreathing. There was no role for the use of breath H2S or HCN in the diagnosis or monitoring of pneumonia in critical illness. There was no relationship between breath acetone concentration and illness severity, however the utility of breath acetone in the modulation of insulin and feeding in critical illness merits further study.

The pharmacy profession is formed of different sectors. The two main ones are community and hospital pharmacists. Sociologists have examined if community pharmacists are a profession or not as a result of their marginalised role in healthcare and links with commerce. Few sociological studies have included hospital pharmacists. This study engaged with the theories from the sociology of the professions such as the neo-Weberian social closure perspective, professions as an interrelated system and Foucault’s concept of knowledge and power to explore the nature of pharmacy practice in healthcare in England, United Kingdom. Its purpose was to reveal new insights into pharmacists’ perceptions of the nature of pharmacy practice linking this to their status in society. This qualitative collective case study consisted of four cases studies. Each case study included five pharmacists from community pharmacy, acute hospital, mental health or community health services, respectively. A total of twenty pharmacists were included. Only pharmacists registered for 5 years or more, who had worked in the relevant healthcare setting for at least 2 years and provided written consent were entered. Data were obtained from one in-depth individual semi-structured interview using a guide covering how they viewed their practice, contributions made to healthcare, their future and how others viewed pharmacists. Each pharmacist was asked to complete a diary for 5 days to include any positive contributions or frustrations experienced. The data for each case were analysed using inductive thematic analysis followed by a cross-case analysis. Five themes were identified; (i) the hidden healthcare profession, (ii) important relationships, (iii) pharmaceutical surveillance, (iv) re-professionalisation strategies and (v) two different professions. The core function defining the pharmacy profession is pharmaceutical surveillance, shifting the sociological understanding of pharmacists’ practice away from dispensing. There is an internal split between community pharmacists and pharmacists in other healthcare settings due to differences in practice, re-professionalisation strategies and relationships with doctors including lacking ideological professional solidarity. Pharmacists are not recognised as healthcare professionals by the public but as ‘typical community pharmacists’ with an image as shopkeepers. Pharmacists interpret professionalism as a controlling rather than an enabling ideology. The status of pharmacists in society today remains unclear.

The series of studies presented in this thesis test an attribution-emotion behaviour model of helping versus violent retaliation (after Weiner, 1995) in professional groups at high risk of encountering violence in the workplace. Weiner's model predicts that staff who perceive violent incidents as within the control of the client will be more likely to experience anger and demonstrate a retaliatory response. Conversely, staff perceiving causes as uncontrollable by the client are more likely to feel sympathetic and exhibit helping behaviour. Emotional responses are seen to mediate between attributions and behavioural responses. A direct link between attributions of control and behaviour is also proposed. These predictions are tested in relation to violent incidents encountered by nursing staff working with detained patients in a psychiatric secure unit, and police firearms officers' in shoot-don't shoot training scenarios. Previous research investigating healthcare staff s perceptions of the causes of challenging patient behaviour reports mixed support for Weiner's (1995) model. Such research could be criticized for its' almost total reliance on the use of hypothetical scenarios, questionnaire methods, and lack of attention to the potential influence of client gender. The studies presented here are unique in that they not only assess spontaneous attributions and reported emotions of staff concerning their management of actual violent incidents, but also take gender into account. An initial pilot was followed by three studies, the first two of these included samples of healthcare staff working with detained patients in a secure unit, whilst the third examined firearms officers in training. The Leeds Attributional Coding System (LACS) was used to code 1) attributions made by healthcare staff in documentation concerning physical restraint of patients, 2) verbatim transcripts of interviews concerning real violent incidents in which heafficare staff had been involved, and 3) firearms officer debriefing interviews following simulated shoot-don't shoot scenarios. The findings from the first two studies suggest that different cognitive processes operate dependent on the gender of the client. In terms of the model tested, the proposed direct association between attributions of control and behaviour was supported, but for males only. Thus, where males were concerned, perceiving the client to have high control was associated with retaliation, and perceiving them to have low control was associated with helping. The role of emotion as a mediator was not supported for males or females. Some further support for the direct relationship between attributions of control and behaviour was found in the third study; police firearms officers' perceptions of high control for suspect were associated with increased frequency of shooting. It is concluded that attributions for client behaviour should be investigated in context, with consideration given to gender. Attributional models of helping/retaliation cannot be applied rigidly across different groups; it is necessary to consider the nature of the population and the circumstances under consideration. Possible explanations of the gender differences found are discussed.