This study investigates the experiences of twenty-two critical care nurses in an attempt to uncover the essential elements in the practice of critical care nursing. The study is grounded in the phenomenological hermeneutics of Martin Heidegger and argues that this methodology is compatible with the humanistic values of nursing. Data were generated from in-depth interviews and overt participant observation. The process of data analysis was guided by Heidegger's notions of phenomenological reflection and hermeneutic circle, Van Manen's (1990) process of thematic analysis and Draper's (1997) analytical principles. Five themes have been identified from the data. These are: (1) 'managing technology' which describes the nurse's relationship with the technological environment of the intensive care unit (2) 'communication with the patient which discusses the nurses' concern regarding the communication needs of the sedated and unconscious patient (3) 'deciding' which explores the decision-making process incorporated by the nurses and draw the attention to the nurses' involvement in ethical decisions (4) 'Humanising care' which describes the humanistic practices that the nurses implement in order not to lose sight of the patient's individual human identity (5) 'coping' which describes some of the situations and dilemmas facing the nurses in the unit with special concern to death as a source of stress and anxiety. The study concluded with an attempt to describe the ontological qualities of the study themes by drawing on Heidegger's concepts of care, involvement, being-in-the-world, understanding, death and his idea regarding our relationship with the technology. When viewed from Heideggerian perspective all the entities in the critical care unit are unified by the concepts of care and involvement which are considered the basic way of being-in-the-world as a critical care nurse. Finally the study suggests some practice and research possibilities.

Aim. The aim of this PhD thesis is to report the sociological position, power dynamics and expertise in the communication between specialist nurses and doctors within NHS acute hospitals. Background. Nursing and healthcare have continually evolved, with new nursing roles interfacing professionally at a more advanced level with doctors. Historically the relationship and interactions have been characterised as the ‘Doctor-Nurse’ game which has been reviewed from many sociological perspectives. However, little has been added to understand the basis of these transactions that take place in the clinical setting between advanced practice nurses and doctors in hospitals. Methods. The primary methods comprised a critical realist approach ethnography, undertaking: fieldwork observations, follow-up interviews and artefact analysis on teams of specialist nurses and doctors working in three NHS hospitals. Seven specialist teams comprising 30 specialist nurses and 53 doctors of all grades were directly studied, alongside other peripheral members of the healthcare team as they delivered care. Results. The findings in this study demonstrate that much has changed concerning the role of the specialist nurse: professionally, clinically and sociologically. Four main themes emerged from the research: defining a new relationship between medicine and nursing; social space, development of ‘field’ in hospital care, division of labour, expertise and a new interaction model. The basis of the relationship has changed through bureaucratic challenges to the medical role which has resulted in changes to nursing power and its application in the clinical field in the new care models. There are a number of new strategies employed by both groups in the management of professional role, knowledge base, expertise and clinical work in the field. The communication strategies are more complex with a sophisticated coalition model of organisation. However, some ‘doctornurse games’ are still played out in the clinical setting, based upon traditional divisions of labour and power. This relationship has also created other tensions in the workspace particularly with junior medical staff, nursing staff and administrators.

Research Question: Is it possible to measure the parent/health visitor relationship? Aim: To develop and validate tools to measure the parent/health visitor relationship. Background: The helping relationship has been the subject of intense scrutiny in other helping professions, particularly psychotherapy where research has shown that it is crucial to positive outcomes for the client. Although health visitors assert that their relationships with parents are also of paramount importance to outcomes, no tools to measure these relationships exist. Methods: An extensive literature review of measures used in other helping relationships across a number of helping professions was carried out to identify their suitability for use in the parent/health visitor relationship. No appropriate measures were found. Stimulated recall interviews were carried out with six parents and health visitor dyads. These were analysed thematically in order to identify indicators of good working relationships. Once identified, TELER dichotomous questionnaires were developed and piloted in the community with 11 health visitors and 36 parents across three Primary Care Trusts and adjusted according to their comments. The newly devised TELER tools were then used with 15 health visitors and 53 parents. The data were analysed using the TELER method and a statistical interpretation made. Results: The outcomes of the study were that indicators of the parent/HV relationship were shown to be measureable together with five major contributions to health visitor knowledge and theory development: 1. Identification of the HV micro-skills and qualities involved in forming working relationships with parents. 2. Identification of the parental contribution to the HV working relationship in terms of their qualities and skills. 3. Identification of the health visiting process. 4. The creation of valid instruments to measure these relationships.5. The creation of a valid instrument to measure the impact of organisations on HV and parent working relationships.

This research investigates the influences on doctors' career and retirement choices. It looks at what influences the career choices of 1993-1996 medical graduates from The University of Manchester (in the North West of England) and also explores what makes-them leave the North West region during this training stage. Doctors in the late stage of their career are also studied to investigate what makes hospital consultants in the North West over the age of 55 retire from the UK's National Health Service (NHS). THE UNIVERSITY OF MANCHESTER ABSTBACJOFTHESI~submittedby Catherine Tregoning for the Degree of PhD and entitled Doctors' Career and Retirement Choices March 2008 . '. ~ .. - ....... ~. ,'., ....;- The research shows that trainees who make career choices based upon an interest in the specialty and/or opportunities as they arise at the time, are more likely to remain in the medical profession. If they have children, they are less likely to remain in medicine. Those who grew-up in the North West or have a partner who originates from the region, can more often be expected to remain in the North West. Furthermore, relocation during training is less likely if an individual has a preference for working with a mixture of deprived and affluent populations. Over 55 hospital consultan'ts are more likely to retire if they obtained their primary medical qualification before 1970, or have a disability or significant health problem. There is also a greater likelihood that they will retire if they consider issues with management to be an important factor in their decision to leave their NHS career. Conversely, they are more likely to remain working in the NHS if achieving their maximum NHS pension entitlement is important to them. The research was conducted in two stages. In stage 1, 47 doctors were interviewed from the two sample groups. The qualitative data gathered, informed the development of a questionnaire distributed to 1, 483 doctors in stage 2. Of these 534 (36%) responded. 32.1% responded from the trainee group and 55.5% from the over 55 consultant group. Pilot studies were conducted at both stages. The research draws upon several different theoretical perspectives to develop the concepts of individual, social and job influences on careers, as well as explore the process of change. The results of the research inform academic work by considering doctors' choices in the context of literature from the fields of careers, medicine and psychology, which has rarely been done. '~lt~aH:f6-U:jKes twOSamples~at different career stages and compares the influences on careers at these different stages. Recommendations for further research include more in-depth investigation of the difficulties for female doctors of combining their career with motherhood, and work into consultants' retirement intentions versus retirement behaviour.

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Non-adherence to medication is a problem of great magnitude as it leads to reduced health outcomes and increased health care costs. The impact of the doctor-patient relationship on non-adherence has attracted the interest of researchers yet relevant evidence is limited. The aim of this thesis is twofold. It empirically investigates the relationship between the doctor-patient interaction and non-adherence to medication in Greece, on a population and a patient level. It also develops a theoretical model of the doctor-patient relationship using non-cooperative game theory to explain how supply of information under conflict conditions affects non-adherence. Two empirical studies and a game theoretical model are used. The first study draws on data from the European Social Survey to examine beliefs about doctors and attitudes towards medication in the general population. The second study analyses a questionnaire survey of hypertensive patients in Greece, conducted for this thesis. The game theoretical approach investigates how conflicts between patients' preferences for information and doctors' effort to supply it may lead to non-adherence. It employs concepts from Behavioural Economics, which combines elements of both Economics and Psychology. The findings demonstrate a strong association between what individuals think of doctors and their attitudes towards medication. Beliefs about doctors are the strongest predictors of non-adherence in both studies. At a population and patient level, Greeks attach a lot of weight to their doctors' opinions and adhere to their recommendations. Finally, the game-theoretical framework shows that doctors' failure to understand patients' need for information may result in patients not adhering. The findings suggest that interventions to improve adherence rates should be built on the basis of a good doctor-patient relationship, where the doctors understand patients' needs, discuss about the treatment and pass on adequate information. The thesis is part of the cumulative knowledge in the area and could lead to further empirical and theoretical investigations.

How can writing exploratively and expressively help people critically assess their life? In what way can a writing process, akin to that used by creative writers to generate first drafts, be a form of critical reflection and reflexivity for personal and professional development? The publications and introductory essay presented in this PhD by Publication thesis examines reflective practice writing for professional development and therapeutic writing for personal development. Both forms use expressive and explorative writing in association with facilitated critical discussion. The publications cover a twenty-five year period of practice and practitioner research enquiry, using narrative, poetry, fictional and autoethnographic-type writing methods. Reflective and therapeutic writing are claimed to form an element within the internationally growing related fields of medical humanities and literature and medicine. The nature of the self which professionals and individuals enquire into through their writing is examined in this thesis, drawing upon an eclectic range of psychological, literary, educational, philosophical and anthropological theories. Narrative and metaphor (natural human forms for self-understanding, learning, and communication) are central to reflective and therapeutic writing. A wide range of professionals have been involved in this research into practice (for example medical, healthcare, education, clinical psychology and healthcare), and different client groups (for example palliative care, and primary care anxious and depressed patients). Explorative and expressive writing for personal and professional development, embryonic areas of study twenty-five years ago, now has high impact potential in social, cultural and professional areas. Although gaining in interest, credibility and presence, they need significant further research to achieve their potential status and value.

Thousands of medical prescriptions are generated everyday by general practitioners (GPs) and one of the most frequently prescribed groups of medicines is antibiotic therapy (Duerden et al. 2011). Despite the many studies that have previously explored clinical decision making, there remains a lack of understanding about how GPs make clinical prescribing decisions. This study was undertaken because the lived experience in clinical decision making has not been widely studied and there is a gap in the literature. This study is the first of its kind to use a phenomenological approach to explore the lived experience and emotional side of antibiotic prescribing in the context of medical prescribing. The aim of this study was to explore, interpret, and understand the lived experience of antibiotic prescribing in general practice. To explore the lived experience of antibiotic prescribing, I used the methodological framework of hermeneutic interpretative phenomenology. Unstructured, face-to-face interviews were conducted with ten GP participants. I transcribed the interviews and based the analysis on Kvale’s six steps of data analysis. Medical prescribing is a complex process based on many factors that include intuitive feelings, clinical knowledge, and professional experience. There are many influences that evoke GPs’ emotions and these emotions then drive the prescribing decision. Influences are both internal, such as the knowledge and experience of the GP and external, such as patients, families, and national policy. Writing a prescription is one of the most frequent procedures undertaken in general practice, yet it often remains a challenging experience and causes many GPs to feel anxious, uneasy, and sometimes overwhelmed. Behind the confident and composed public face of GPs lies a professional group of clinicians who are caring and empathetic but often feel anxious and vulnerable. The findings of the study have implications for practice, education and research.

The purpose of the present dissertation has been to provide insights into the role of cultural mediators in enhancing patients’ empowerment medical encounters. Specific attention was paid to relations of power between mediators and heath staff understood in terms of the attribution of value to resources of knowledge. The research takes a linguistic ethnographic approach to examining mediation within healthcare settings. Data-gathering techniques included recorded mediated interactions, interviews with healthcare staff and mediators, observations, analysis of hospital documents and visual material. Findings show that mediators have a considerable impact on patients’ empowerment. The data seems to confirm that mediators empower migrant patients in those cases when patients seek information and express concerns. Nevertheless, the research demonstrated that mediators prevent patients’ participation and maintain the status quo of the healthcare system when patients make decisions and express refusals. The findings demonstrate the need to implement training programmes for both healthcare providers and mediators to become more aware of their role of coordinators in the interaction. Additionally, there is a need for heath staff to attribute a higher value to mediators’ cultural capital and the need for healthcare institutions to recognise mediators as a professional group.

The consultation between an individual patient and doctor is the bedrock of general medical practice. Varying perspectives on the nature and purpose of this interaction are apparent in the writings about the general practice consultation over the last half-century. The view of the consultation that underlies this study is that it is a social act whose nature and characteristics are determined in interaction between the doctor and patient and not by the activities of the doctor alone. The aim of this study is to explore how general practitioners experience satisfaction with their everyday consultations. Nineteen general practitioners took part in the study. They each audio-tape recorded between 25 and 30 consultations with consecutive consenting patients. They scored each consultation according to how satisfying they found it on a scale of 0-10, where 0 was maximally dissatisfying and 10 was maximally satisfying. A sample of six consultations from each doctor were chosen to include the most and least satisfying and these formed the basis of an in-depth qualitative interview between the doctor and myself. The data from the interviews was analysed using constant comparison to elucidate the doctors' views about their consultations and the reasons for consultations being satisfying or not. The empirical findings of this study reveal that the way doctors experience satisfaction in consultations relates to four broad issues. First their evaluation of their technical performance in the consultation, in particular their deployment of their clinical skills and their communication skills. Second the way they morally evaluate the patient and the purpose of this evaluation in the conduct of the consultation. Third the sense they have of knowing the patient which is seen to be qualitatively different from their knowledge about the patient. And finally the sense that the experience of the consultation is congruent with their knowledge of themselves as a doctor and thus is implicated in them maintaining a positive selfidentity. On the basis of these empirical findings a loose conceptual model of how general practitioners experience satisfaction in their work is proposed. The findings of the study are seen to have implications for the organisation and delivery of primary medical care, for the training of doctors and general practitioners and for the conduct of general practice research.