Background: Providing an effective exercise prescription process for a patient with non-specific chronic low back pain (NSCLBP) within the limits of time that a busy clinician faces is a challenging task. Emerging research has indicated that partnership in care and shared decision making are important for people with NSCLBP, and calls for further investigation into the approaches used to prescribe exercise. Objective: To explore the characteristics and processes of physiotherapy exercise prescription for patients with NSCLBP, and investigate how shared decision making and patient partnership are addressed by physiotherapists in this process. Design: A qualitative study using a philosophical hermeneutic approach. In phase one of the study eight physiotherapists were each observed on three occasions undertaking their usual clinical activities. They participated in brief interviews after each observation and a later in depth semi-structured interview. In phase two semi-structured interviews with eight patients including use of some brief patient vignettes was undertaken to provide a rich descriptive text of their personal experiences of receiving exercise as part of the management of their NSCLBP, and their involvement in decisions regarding their treatment plans. In depth iterative hermeneutic strategies were used to interpret the texts and identify the characteristics and processes of exercise prescription for patients with NSCLBP. . Analysis: Thematic analysis (Braun and Clarke, 1996) was employed to search for themes and patterns from the observations and interviews with physiotherapists and patients. Findings: The findings provide a complex understanding of how physiotherapists regard and utilise exercise based management strategies for patients with NSCLBP. Patient partnership and shared decision making were rarely evident and were linked to the physiotherapists’ clinical orientations, cognitive and decision making processes, and assumptions about patients. The overall feeling of the patients was that the role they played in the therapeutic interaction was a marginal one, such that the therapist was dominant in structuring the interactions, leaving the patients feeling disempowered to question and contribute. Conclusions: This research, by focusing on a patient-centred approach, makes an important contribution to the body of evidence relating to the management of NSCLBP. It challenges physiotherapists to critically appraise their approaches to the prescription of exercise therapy in order to improve outcomes in these patients.

Rheumatoid arthritis (RA) is a chronic, inflammatory auto-immune disease. Fatigue is a major symptom of RA and has a considerable impact on patients' daily lives. RA patients report that they struggle to manage their fatigue and receive little professional support. Currently there are no physical activity (PA) interventions that have been specifically designed to manage RA fatigue. However, secondary outcomes for fatigue in PA trials in RA suggest that it may be beneficial. This is supported by evidence in other long-term conditions. A pragmatic mixed methods approach was undertaken to explore the potential use of PA to manage RA fatigue and to develop a PA intervention specifically for fatigue management. A series of iterative studies was conducted using a range of methodologies, including systematic literature reviews, semi-structured interviews, focus groups, systematic intervention development and a proof-of-concept study. A review of existing evidence demonstrated a small beneficial short-term effect of PA for managing RA fatigue but this was based on secondary outcomes in low quality studies. A lack of evidence was also identified for theory-based interventions to promote engagement in and long-term maintenance of PA in RA. Semi-structured interviews with healthcare professionals (HCPs) delivering existing PA interventions in other long-term conditions confirmed a lack of an explicit theoretical basis for these programmes. However, participants acknowledged the importance of addressing motivational and psychosocial issues in order to change PA behaviour in patients with fatigue. Programmes varied in terms of format and delivery, but consistent findings included graded approaches to exercise and a flexible approach to implementation and delivery. Findings were subsequently discussed in focus groups with RA patients and rheumatology HCPs. Preferences for similar interventions in RA were identified, for example, a face-to-face group programme incorporating a practical PA session to develop self-management skills and address barriers to PA. Practicalities regarding implementation were noted, including staffing and resource issues. Existing evidence and primary data generated by the qualitative studies were used to develop a PA self-management programme using the Behaviour Change Wheel, a theoretical framework for behaviour change interventions. The novel intervention was delivered to a group of RA patients to model implementation and delivery processes and to explore acceptability. Findings suggested that the intervention was deliverable, and content and support materials were acceptable to this group of participants. These findings have implications for clinical practice as RA patients and rheumatology HCPs acknowledged that current fatigue management could be improved. The use of PA for managing fatigue was supported by patients and professionals. This theoretically-informed intervention should now be considered for further evaluation in a feasibility and pilot study prior to full scale testing in a randomised controlled trial.

Background: Coeliac disease is an autoimmune disease triggered by an inappropriate immune response to dietary gluten. This condition affects around 1% of the population and can lead to serious health complications, including nutrient deficiencies, infertility, osteoporosis and cancer. Symptoms, such as diarrhoea, pain, fatigue and bloating, can be debilitating. The only treatment is a life-long gluten-free diet. Up to 58% of adult patients have sub-optimal adherence to a gluten-free diet, yet the reasons for this are poorly understood. The aim of this study was to gain a better understanding of the factors affecting adherence to a gluten-free diet in adult coeliac patients. Methods: Concept mapping is a participatory mixed method that involves generation of ideas through brainstorming. Ideas are prioritised and grouped for similarity by participants, producing visual concept maps that represent participants’ perceptions about what affects adherence to a gluten-free diet. Results: Seventy-three participants were recruited (34 adult coeliac patients; 21 adults who live with them (household members); and 18 healthcare professionals). Analysis revealed a concept map containing 13 thematic clusters: The high cost of gluten-free food was perceived to be the most important factor. Healthcare professionals perceived the availability of gluten-free sandwiches to be significantly less important than people with 3 coeliac disease and household members. Other factors included: knowledge and information about coeliac disease and the gluten-free diet; access to gluten-free food; motivation and support; and difficulties eating away from home. There was a high degree of consistency between the perceptions of the three stakeholder groups. Conclusions: This study identified a complex interplay of factors associated with adherence to a gluten-free diet and their relative importance. This study provides a better understanding of how to support adherence to a gluten free diet in adults with coeliac disease. This knowledge could be used to inform interventions to improve dietary adherence.

This PhD by publication brings together several pieces of research undertaken in order to explore issues in advanced practice in a number of different settings. The focus of the programme of work has been to gain a better understanding and widen available knowledge of the drivers and essential elements of advanced practice nursing roles. The whole body of the work is based on my continuing academic and professional role embracing clinical practice and education as well as research. It is my strongly held belief that these three components are intrinsically linked and that one without the others, for professionals in practice, is incomplete and inherently flawed as an underpinning to the work of health care professionals. The work on this thesis began because of concerns and issues around personal practice and has grown to involve national and international perspectives on a number of clinical areas. This programme of work with each new study considering different aspects of advanced practise while building on the results and conclusions of the preceding works, leads to a consideration of some of the implications for future practice, education and research in this important area of nursing. The opportunities for research were, in the main, on a small scale and unfunded. Qualitative techniques were chosen in order to explore the ideas and experience of the participants, rather than those preconceived ideas held by the researcher(s). The demographic and quantitative data collected in the surveys was represented by descriptive statistics only as no inferences (in a statistical sense) could possibly have been drawn from such data. The publications associated with the planned areas of enquiry add to the evidence base for advanced nursing practice and seek to promote discussion and debate and promote change around an essential element of healthcare provision. The studies consider aspects of advanced practice including: " Decision making and safety: Decision making reflects expertise and has been shown, in the work here as well as in many other areas, to be safe and effective. 9 Acceptability of roles: There is a huge volume of research available that shows overwhelmingly that patients like these advanced practice roles. Research undertaken here showed the acceptability of the role to the multidisciplinary team and the importance of the whole team to role functioning. " The organisation of advanced practice: Some issues identified in the study relating to aspects of role development such as prescribing, have subsequently been successfully addressed. Others, such as the rigidity of job descriptions and the lack of support for risk taking, still prove problematic, " The process of role development is, as has been highlighted in other literature, often ad hoc, local, ill thought through and without the infrastructure to support it. Nevertheless, roles are evidently successful. " Regulation of advanced practice: What has become clear throughout the process and the time span of the programme of research is that whether regulation is in place or not, nursing responds to the needs of the service and while regulation of one part of nursing ensures that the particular advanced practice role is protected, others evolve outside the framework as easier (and cheaper) options. " Policy as a driver of roles: It is clear that policy, whether local or national drives the areas in which advanced practice flourishes. Where there are gaps in service, nurses and now other health professionals undertaking such roles, move in to address the service imperatives. The nature of healthcare is about to change quite fundamentally in the UK, and if we are to be able to know what is going on and the effect it is having, research on advanced practice roles must continue. My intentions are to build on this work in the future and include replication studies as well as studies employing sequential explanatory designs to widen the scope of the research presented here. Other areas of potential research include outcomes for patients in acute care settings as well as issues such as value for money which, at present are very difficult to quantify. As nurses move into even more complex roles, it will also be important to keep an eye on the educational underpinnings of such roles. The private sector is playing an increasing part in the UK's health provision and, with a diverse range of organisations involved, little is known about advanced practice roles in these organisations. This gap in the original research, coupled with the much wider role of such providers in the future, also opens up future research possibilities.

Previous research has indicated that nurses may hold moralistic or stereotypical views of illicit drug users, suggesting that such views may influence the care provided to a potentially large number of patients. The current study aimed to identify the factors influencing the pre-existing attitudes of student nurses toward illicit drug use, ascertain if these attitudes changed over the first year of training, and discover if any changes were specific to nurse education. No previous studies could be found which measured the impact of a range of variables on attitudes toward illicit drugs or longitudinal changes in attitude during nurse education. A mixed methods design was employed, with student nurses and comparison groups of clinical psychology trainees, health and social care, social work and midwifery students completing an anonymous questionnaire at the start of their course (N=311). This questionnaire measured the students’ attitudes and collected data on a range of variables identified as significant in terms of attitudes to illicit drugs. The questionnaire was reissued to the same students at the end of their first year (N=267). Semi-structured interviews were also conducted with volunteers, from the students who had completed the questionnaires (n=25). Results found that students who self-reported personal use of illicit drugs or were aware of use by family/friends expressed more positive attitudes. Student nurses indicated less tolerant attitudes than the other groups of students and minimal changes in attitudes were detected over the first year of training for all student groups. However, the student nurses’ attitudes increased, whereas the comparison groups all decreased. The study highlights the need for a specific educational focus on illicit drug use, as simply entering nurse education appears insufficient in addressing negative attitudes. However, any educational approach aimed at improving attitudes needs to take into account the students’ previous experiences around illicit drugs.

There has been an absence of research that explores the combined effect of experiencing a patient’s suicide or unexpected death and the subsequent process of professional scrutiny that frequently follows such a death. This is a qualitative study utilising constructivist grounded theory that explores the experience of fifteen mental health nurses from four NHS trusts and their response to a patient suicide or unexpected death. The study considers how the death and the resultant process of professional scrutiny affected the nurses both professionally and, for some, personally. This research is placed within the context of what is known regarding the effects of professional scrutiny, the psychological impact of adverse events, and the broader concepts of responses to adverse events referred to as ’second victim’ phenomenon (Wu and Steckelberg 2012). The findings of this study identified several areas that demonstrate the impact of an unexpected death or suicide on the nurses. The participants all experienced varying degrees of psychological distress, which for two were similar to experiences more normally associated with post-traumatic stress disorders. The psychological response to the distress of the death and process of scrutiny was similar to that found in second victim studies. However the nurses in this group did not believe they had made an error, often a factor associated with second victim studies. The study found that the type of relationship with the service user is an important denominator in determining how the nurse reacts to the death. The process of professional scrutiny further compounds this. Nurses’ report that they are unable to find psychological closure until the scrutiny, particularly the coroners hearing, has concluded.

Male homosexuality was illegal in England and Wales from 1533 until 1967 and, along with transvestism, was considered an antisocial 'sexual deviation' that could be 'cured'. Nurses were involved in administering treatments to cure these individuals. This study used oral history interviews with fifteen nurses, along with documentary sources, to examine the meanings that nurses attached to these treatments, and represents the first attempt to examine nurses' perceptions on providing such treatments. The study also conducted oral history interviews with seven patient's and explores their experiences of receiving these treatments to obtain a better understanding of the topic in question and claim a 'history from below' which allows us to see historical practice from a new perspective. The period examined by this thesis was 1935 to 1974. It begins with the publication of the first official report on the use of aversion therapy to treat homosexuality. This publication, along with prejudicial attitudes towards homosexuals and transvestites in the media and in literary, medical, sociological and legal discourses, provided some momentum for the use of aversion therapy to cure these individuals. The period ends in 1974 with the seventh printing of the American Psychiatric Association Diagnostic Statistical Manual version II, which removed homosexuality as a category of psychiatric disorder in the USA. None of the patients in this study reported that the treatment had been effective and all were left feeling emotionally troubled by it. The study explored a number of influences that may have motivated nurses to administer these painful and distressing treatments. Nurses' work was largely constrained by the asylum-type conditions in which they worked, and the character and quality of patient care was largely influenced by the medical staff, who appeared to have overriding control of both the institution and the nurses working within it. In addition, due to their limited knowledge base, nurses believed that it was pertinent for the well-being of a patient that nurses obey medical orders. They took on the status offered to them of obedient order-takers. Nevertheless, from accounts gathered during this study, some nurses covertly undermined their superiors and engaged in subversive behaviours to avoid participating in this aspect of clinical practice. The thesis offers a hitherto undiscovered insight into the role of mental nurses caring for patients receiving aversion therapy for sexual deviation. In doing so, it provides insights into the way nurses may behave when a particular set of social, political and contextual factors are at play. As the first study to focus on exploring the nurses' role in caring for sexually deviant patients, it provides in-depth historical analysis of this subject and related issues as well as a basis for further historical analysis in this area. It is envisaged that this study might also act as a reminder of the need for nurses to ensure that their interventions have a sound evidence base, and that they constantly reflect on the moral and value base of their practice and the influence that science, societal norms and contexts can have on changing views of what is regarded as 'acceptable practice'.

Despite the potentially very significant role of nurses in mitigating against the negative effects of hospitalisation on children, the attitudes and behaviour of paediatric nurses towards patients have been largely ignored within the literature. This study, therefore, aimed to consider paediatric nurses' attitudes and their interactions with patients and, in particular, to investigate the relationship between these two variables. However, in contrast with similar studies in other specialties, nurses' attitudes and behaviour were considered at a general and individual patient level. A general attitude measure, the Paediatric Attitude Scale (PAS), was developed during the first part of the study and indicated that nurses' attitudes towards patients as a whole tended to be tolerant and patient-centred. Nurses' interactions with patients were mainly positive and, in contrast with previous research, regularly occurred outside of the normal nursing routine. In addition, almost half of all nurse-patient interactions contained a social component. As predicted, no significant association was evident between nurses' scores on the PAS and their general behaviour with patients. However, modest associations with correlation ratios of between 0.10 and 0.16 were found between nurses' attitudes towards individual patients (as measured by ranking scales) and the quality, duration and, to a lesser extent, the number of interactions with those particular patients. Indeed, the results suggested that patients who were liked more and who were considered easier to nurse tended to receive interactions which were more positive and longer than patients who were liked less and who were perceived to be more 'difficult'. However, the actual differences between interaction scores for particular patients were relatively small and their clinical significance in terms of the impact on children and the need to modify nursing practice is, therefore, debatable.

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