Introduction and Background: This thesis presents ten published papers linked by the need to come to a better understanding of health across different settings and contexts. Central to the concept of health is the principle that settings play a pivotal role in shaping positive health outcomes for people and populations. The introduction of the concept of a settings approach to better health is usually attributed to the World Health Organisation (WHO), since its first mention in the Ottawa Charter (1986). I have used the concept of a settings approach (WHO 1986) to understanding health in order to draw the papers in this thesis together. Helping Nurses Understand Health to Promote Health in Practice. The idea that nurses are well placed to contribute to positive health in practice settings is well versed within the literature and it is in this context that the first published papers (1-5) and two book chapters are presented. As the publications in this thesis around nursing and its role in promoting health took shape, public health policy drivers from Government and from nursing’s professional body continued to emerge (e.g. DoH 1999, 2000, 2004, 2006, 2010, HEE 2015, NMC 2010, RCN, 2012). The papers in this section of the thesis demonstrate the challenge for nurse educators, in particular responding to an ever-changing NHS and the demands and expectations from those we nurse. Health in University Settings My work within the UK Healthy Universities Network led to external work for Papers 6 and 7. These focus on student health in universities, and the wider needs of students in such settings. It presents universities as settings for health, which can support students (and staff) using a whole systems approach. This section of the thesis provides the reader with glimpses of how health and, what creates health, is intrinsically linked across different settings and, how nurses can use settings such as universities to explore health and what creates health. Health in Work Place Settings Health and wellbeing in the workplace is a concept that is understood as a fundamental business case for a productive, happy, and healthy workforce. The workplace is also a setting by which knowledge and skills about health can be disseminated to assist people, in improving their health and wellbeing. The final paper in this thesis (paper 8), explores the main health and wellbeing needs of a sample of Small and Medium sized Enterprises (SMEs) across Greater Manchester. This work resulted in some unanticipated findings in terms of what creates health for people in SMEs, in particular that of quick fix public health interventions. It provides the reader with, an alternative lens in which to view health and health needs in the workplace. Summary The papers within this thesis and the contribution of the work that enabled their development, is intrinsically linked by the ideology of settings as places where people experience health and, what creates health for them in those settings. Being a nurse is at the heart of this thesis, it is where it begins, and this is where the thesis returns to at the end. Within this thesis, I have explored health in different settings through a research lens. From this, I am able to propose that by taking a settings approach to understanding health through the undergraduate nursing curriculum, alongside the use of non-traditional settings (e.g. universities and workplaces) for student nursing placements, nurses may then truly understand health and what creates health, for those they work with and care for. The papers, and subsequent work that has resulted from them, have enabled me to be at the cutting edge of nurse education. I have represented these within the thesis as a timeline linked to how these changes influenced my work and, my contribution to nurse education, workplace health, and health within universities.

This study involved student nurses, lecturers, mentors and service users in working together to design, evaluate and refine a system enabling student mental health nurses to seek feedback from service users. The feedback concerned students' interpersonal skills and occurred in practice, at the point of service delivery. Although the drive to engage service users in service delivery, research and education has mainstream acceptance, much remains to be learned about how to achieve meaningful involvement. Mental health professionals are striving to adopt the recovery model and harness service user expertise through the development of more reciprocal relationships. This research aims to contribute to this wider thrust, by exploring the experiences of those concerned when students attempt to learn from rather than about service users. Conducted over two years, a participatory action research approach was adopted. Data came from interviews held with those implementing the system for feedback, and from the deliberations of the participants guiding the process. Thematic analysis produced evidence of relevance to nurse educationalists, mental health nurses and researchers. Although contextual, findings indicated that service users volunteering to give feedback had a positive experience. Students' experience lay on a continuum. Those with a stronger sense of self were more willing and able to ask for feedback than less confident students. Cultural adjustment to the role change required presented a challenge and tested self-awareness. Over time, all students achieved deep learning and, for some, learning appeared transformative. Recommendations relate to the system for seeking feedback and the conduct of participatory action research. Overall, the study concluded that both allowed the development of more equitable relationsh ips, in which mental health nurses respected the expertise of service users. This potentially benefits student development, recoveryorientated practice, service users and Higher Education Institutions searching for meaningful ways to involve service users in learning and formative assessment.

Background This study was instigated in response to the researcher’s own realisation, as a rehabilitation practitioner and educator, that the concept of rehabilitation as identified in the literature may not be culturally sensitive. This view was prompted by the researcher’s interactions with international students undertaking an MSc in Rehabilitation at Oxford Brookes University in the UK. The literature defining and describing rehabilitation generally appears to be from Europe (including the UK), Australia and the USA with an emphasis on concepts and values such as independence, autonomy and individualism, which appears to represent the values the of the Western countries from which the literature originates. This view is supported by Saadah (2002) who identifies autonomy as such a concept, which is identified as the aim of rehabilitation in the literature (Cardol 2002a) and calls for a structural framework for rehabilitation based on understanding of different cultures and culturally sensitive care. Aim and Objectives The main aim of this study was to examine the concept of rehabilitation in the literature in relation to cultural sensitivity in order to gain new interpretations and understandings for rehabilitation practice and education. The objectives being to discover if there is an essence or core of rehabilitation that transcends culture; whether the International Classification of Functioning, Disability and Health (ICF) (WHO 2001) is suitable for use as a cultural framework and to identify implications for practice and education. Methodology and Methods Concept analysis (Morse 1995) was the research approach used as it fits in with the conceptual assumptions of the study and enabled the researcher to analyse the literature in depth in order to explore the concept of rehabilitation in relation to cultural sensitivity. Morse’s approach was followed with the fundamental difference being the addition of qualitative data which were analysed along with the literature. The data were collected from a university and hospital in Manipal, South West India. A literature review was conducted accessing PubMed, CINHAL, AMED, PsycINFO, NARIC and IndMED data bases using inclusion and exclusion criteria. Following management of the literature using the ICF (WHO 2001) categories and critical appraisal a sample of 120 articles was identified. Thirteen patients with neurological or orthopaedic conditions undergoing rehabilitation were interviewed using qualitative interviews, seven focus groups were conducted involving physiotherapy, occupational therapy and nursing students, health care professionals and lecturers and participant observation was conducted. Main Findings The literature and qualitative data were analysed following Morse’s concept analysis approach to establish the level of maturity. This enabled the concept of rehabilitation to be deconstructed in terms of its components (attributes, definitions, attributes, pre-conditions, outcomes and boundaries). As a result the concept of rehabilitation in relation to cultural sensitivity was identified as being mature in relation to pre-requisites, boundaries and outcomes but only partially mature in respect of definitions and attributes. A key finding of this stage is that rehabilitation needs to be meaningful to the person and their family. This then led to the next step of concept analysis: concept clarification, where critical questions were asked of the data in order to advance the concept in relation to cultural sensitivity. As a result, culturally safe rehabilitation, external factors, family centred decision-making and meaningful rehabilitation were all identified as being integral to the concept of rehabilitation being meaningful to the person and their family. Conclusion A key contribution of this study to the body of knowledge on rehabilitation is that, in order for rehabilitation to be culturally sensitive, it needs to be meaningful to the person-in-their-family-in-their-cultural context. This can be seen as the essence of rehabilitation that transcends culture. In order for this to happen, rehabilitation needs to be emergent: responding to the needs of the person in their cultural context with professionals allowing for variation in individual experiences and perspectives. These elements have been combined into a framework with the person-in-their-family-in-their cultural context at the centre. However, the findings and recommendations need to be treated with caution as they are based on a small sample of data representing one area of India with a limited number of participants and literature that is only representative of the country and discipline in which it is written. There are also other limitations in terms of data collection, data analysis and interpretation of results. Future research is required to explore the idea of ‘meaningful rehabilitation’ for patients and their families and to evaluate the framework in practice and in education.

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Nurses working in haemato-oncology require specialised knowledge and yet, formal education programmes and textbooks devoted to the speciality are limited. In advancing knowledge for haemato-oncology nursing practice this project endeavours to develop, synthesise, organise and disseminate available evidence making it more accessible to practising nurses. The project consists of two inter-related parts: reflection on, and critique of, the development and editing of the second edition of a nursing textbook and a Delphi study of research priorities in haemato-oncology nursing included as a chapter of the textbook. In aiming to expand and advance the knowledge base for nurses working in haematooncology the concept of knowledge, ways of acquiring knowledge and types of nursing knowledge are explored and critically analysed. A textbook is mainly a source of empirical knowledge but ways of encouraging the development of other forms of relevant knowledge are discussed in relation to the format of the textbook. Critical reflection on the development of the textbook is also undertaken to detennine usefulness and value. Development of the first edition of the textbook and analysis of existing literature in haemato-oncology nursing highlighted the paucity of research informing the speciality. This provided the incentive to undertake the Delphi study. Round 1 generated a wide range of research topics, subsequently used to develop the questionnaire for round 2. Round 2 results demonstrated close clustering and little discrimination between research topics. Round 3 was therefore undertaken to increase the reliability and credibility of results and further discriminate between research priorities. Results from rounds 2 and 3 were remarkably consistent with several strong research themes emerging. These themes provide the foundations for the development of a research strategy with the potential to further advance knowledge for haemato-oncology nursing practice.

This project focussed on the experiences of healthcare continuing professional development students in a higher education institution. A scoping exercise indicated that although there was a focus on the student experience, this did not necessarily extend to healthcare CPD students. The project comprised two research questions and subsequent lines of enquiry: What factors do key stakeholders believe need to be taken into account in healthcare CPD curriculum planning, development and delivery?, and What is the nature of the student experience for healthcare CPD students studying at Middlesex University? The stakeholder–curriculum line of enquiry used an action research-based approach. Two cycles of activity took place, based on feedback from key stakeholder groups. Thematic analysis of data from the stakeholder groups was used to produce a draft Curriculum Principles Document that was piloted in practice. Interview data provided by the curriculum developer were used to produce a final version, along with a Staff Guide. Data for the student experience line of enquiry was collected from questionnaires and a focus group. Analysis of data from the questionnaire enabled the construction of a healthcare CPD student profile. Focus group analysis generated seven themes, two of which were new perspectives: perception of self as a University student, and the lone study experience. It is argued that there is a conceptual dissonance between the professional body requirement to engage in lifelong learning and CPD activities, and the reality of that engagement in a higher education context. A healthcare CPD student transition model is proposed. Findings from the student-stakeholder group and the focus group were used to produce recommendations for education practice based on a four-point model for enhancing the healthcare CPD student experience: 1) preparation for CPD study; 2) teaching, learning and assessment strategies for CPD; 3) multi-stakeholder, solution-focussed University services; and 4) a healthcare CPD consultancy and advice service. Recommendations for future research based on the concept of engagement and transition for other professional groups engaged in CPD are suggested. The implementation of this healthcare CPD student experience project has provided new insights into the healthcare CPD student experience leading to the development of a model aimed at enhancing that experience. As a result of dissemination of findings, CPD students have a higher profile within the University.

Diabetes is emerging as a clinical practice and educational concern in mental healthcare. However, there is little research into the diabetes education and skills needs of practitioners such as Mental Health Nurses. Furthermore, there is very little research into Mental Health Service Users experiences of diabetes or diabetes care and how these could be used to enhance the education and training of Mental Health Nurses in this area. This research project used a mixed methods research approach to explore Mental Health Nurses diabetes education and skills needs from the view of both Mental Health Nurses and Mental Health Service Users. A quantitative Training Needs Analysis survey was undertaken in 2008 with a sample of 220 Mental Health Nurses regarding their diabetes care education and skills needs. 146 responded giving a response rate of 66%. The results of this survey where used to develop a qualitative interview schedule to explore the experiences of diabetes care of a purposive sample of seven Mental Health Service Users in 2011 and how these experiences could be used to inform Mental Health Nurses diabetes education and training. This study found that diabetes care is becoming a frequent care activity for Mental Health Nurses. While the sample reported prior training in diabetes care, this was predominantly in the period of student nurse training. This has an implication for the currency of clinical skills and knowledge. Mental Health Nurses reported varying levels of general and specific knowledge of diabetes. They also reported varying levels of confidence in aspects of diabetes care such as recognising symptoms of diabetes, knowledge of local diabetes services and liaison with local diabetes services. There was a recognition that further training was required and the sample reported high levels of motivation to attend training and retain diabetes care as an area of Mental Health Nursing practice. Mental Health Service Users reported negative experiences of diabetes care. This consisted of stigma, diagnostic overshadowing, a splitting of mental and physical health and low levels of confidence in Mental Health Nurses ability to provide diabetes care. Service Users broadly agreed with Mental Health Nurses expressed training needs but felt that education and training on stigma and how this can be a barrier to diabetes care is a priority area for education. This study recommends that Mental Health Service Users experiences of physical illness, in this instance diabetes, should be a foundation part of any training and education of Mental Health Nurses in this area. This is because these experiences can promote critical reflection on practice and encourage professionals to reflect on negative attitudes that may be an unwitting barrier to care. It also recommends that service users are more involved in identifying education and training needs so that education is responsive not only to the needs of nurses and Higher Education Institutions, but service users also.

This study aimed to investigate the cultural competence and transcultural nursing experiences of community nurses in a local health service area in response to increasing demographic change and cultural diversity. In response to a dearth of evidence-based transcultural nursing research in the Irish context, this work-based project primarily explored practice, service delivery and professional development within an individual and localised service context. The study was informed by my own professional role as a Clinical Nurse Specialist working with asylum seekers in the Health Service Executive organisation. A flexible research design was employed, using a mixed methodology of quantitative and qualitative methods. To determine levels of cultural competence, quantitative data was collected and analysed using a specialised cultural competence assessment tool (CCAT Survey Questionnaire) and software. A total population of 44 nurses (N=44) were surveyed in Liffeyside health service area. 54.4% (n=24) completed and returned the CCAT survey. It revealed that nurses in this study were ‘culturally aware’ in accordance with the specific assessment criteria used. The main findings from the study stem predominantly from the qualitative research and the interpretative analysis, in which a number of themes and sub-themes emerged. Qualitative methods consisted of semi-structured individual interviews using a purposive sample from the community nursing population of the area. This allowed for more in-depth exploration of nurses’ transcultural experiences. Nurses tended to be unfamiliar with the professional discipline and practice of transcultural healthcare. Community nurses mostly acquired their transcultural knowledge from their work but tended to undervalue this type of knowledge. Overall, community nurses appeared interested in offering culturally competent care and were aware of the importance of developing and maintaining therapeutic relationships with ethnic minority service users. Although keen to offer an equality of service, the data demonstrated personal, professional and organisational barriers that led to tensions and ambiguity that impacted on nurses’ capacity to further develop their cultural competence. When working with ethnic minority clients, nurses appeared conflicted and complacent at times. In the main, nurses were content to ‘just get by’. Nurses were uneasy with some aspects of working with cultural diversity, for example, in the area of the use of language and terminology and this appeared to affect their confidence in addressing issues. A reluctance by nurses to name, acknowledge and challenge racism as a specific form of discrimination within the community nursing service was evident. Opportunities to improve and build on the development of cultural competence within this environment were identified. A number of practical suggestions for nurses and management are recommended, including practical guidelines, structured formal transcultural placements, education and interdisciplinary collaborative work and research.

This thesis documents a research programme into the use of Patient-Focused Hybrid Simulation (PFHS) for clinical skills education. PFHS is an approach to simulating clinical skills that combines a simulated patient (SP) with a part-task trainer (PTT) embedding the simulation of procedural skills within a more holistic clinical context, potentially overcoming some of the shortcomings of single modality simulation. Although promising, there remains limited evidence supporting its use. Two studies were conducted using a mixed-method approach. The first study was based on the simulation of the management of a traumatic skin laceration and consisted of two parts: 1) investigating the use of PFHS as a means of introducing clinical challenge by modifying the clinical context in which a procedure is performed; 2) exploring clinician's perception of the use of PFHS and PTT for assessing of clinical competence. These findings suggest that by changing the clinical context in which a procedure is performed, PFHS can potentially be used to objectively simulate challenge. It also demonstrated that PFHS when compared to PTT simulations was better able to induce authentic clinical behaviour within the simulation. Central to this is the presence of a human being (SP). The second study compared the use of PFHS to patients for the training and assessment of cardiovascular examination skills. Within the limitations of this study, no significant difference was observed between PFHS and real patient-trained students in terms of their post-training performance of cardiovascular examination on real patients. There also appeared to be degree of concurrent validity between assessment of competency with PFHS and with real patients when conducted as an Objective Structured Clinical Examination (OSCE). The work presented provides additional evidence to the existing literature to support the use of PFHS in clinical skills education. However, it also raises a multitude of questions particularly of how PFHS as well as simulation in general should be used and future directions for simulation research.

The history of nursing in South Arabia (SA) during the late colonial period has not been well researched. This study aimed to provide a comprehensive account of nursing services and training in the region from 1950 to 1967, against the background of the colonial context and the local setting. This research was conducted through the gathering of first-hand accounts. These were carried out in the form of oral history interviews with both South Arabian nurses and British nurses who worked as nurses in SA. In addition, the research draws on data obtained through documentary and archival research. The study found that, although nursing services were enhanced and amplified in SA between 1950 and 1967 by the British colonial administration, there was a lack of government and institutional planning, and the provision of nursing services was variable and uneven. Nurse training was basic and variable, with males tending to receive more professionalised training than females. Furthermore, the benefits of colonial nursing services brought to the population as a result of the colonial presence was as much by individual endeavor and the work of charitable organisations (such as the British Red Cross), as it was by any sort of overall intention on the part of the colonial authorities. This research has shown that in addition to the absence of overall planning of the nursing services during the period of the administration, the colonial dominance was extended through nursing in many ways: the colonial nurses dominated the nursing workforce; the local expertise was undervalued; and nursing management positions were limited to the colonial nurses. This study contributes to our understanding of the history of South Arabia and should also be of particular interest to scholars who have an interest in the history of nursing during the colonial period.