Clinical Nurse Specialism was established in Ireland in 2001. As this new role has become embedded in practice over the past decade it has faced a number of challenges. The unsatisfactory articulation of the nature of the work at the level of clinical nurse specialist was described by Seymour et al (2002). The aim of this study was to establish a clear insight and understanding of the role of the Community Clinical Nurse Specialist in Palliative Care (CNSPC) in the South of Ireland. As many studies have examined the CNS role from within the profession, of particular importance here were the perspectives held by patients, family members, and other healthcare professionals. A qualitative approach through a combination of focus group and semi-structured interviews were held with a range of health care professionals including five focus groups of CNSPC, two General Practitioners (GPs), three focus groups of Public Health Nurses (PHNs) and a nurse representative of the National Council for the Professional Development of Nursing and Midwifery (NCNM) was used. Through purposive sampling four patients and three family members consented to participate in face to face semi-structured interviews on invitation by their CNSPC. Non participant observation was conducted at two team meetings. Thematic analysis (Braun and Clarke, 2006) of the data was undertaken in an attempt to understand the perception of the patients, family members and healthcare professionals. Three themes emerged following analysis. These were journey as a metaphor, aspects of care and role. From the time of referral to palliative care in the community the CNSPC accompanied the patient on their journey. The CNSPC joined the GPs and PHNs to establish a connection in an effort to guide the patient and family members on the path to their destination. Aspects of care featured the concern, regard and mindfulness of the CNSPC through caring and supporting the patient and family members. In addition, these aspects of care incorporated the team and were delivered through teamwork. The final theme was role, including the elements of role structure and role model. Though role structure captured both the expected and enacted role of the CNSPC, role ambiguity was also encountered. Role conflict and strain were represented as an expressive role but were also accompanied by the interpersonal contact essential to individual relationships. Recommendations of this study included the clarification of the role of the CNSPC and subsequent dissemination to relevant personnel. By considering solutions that can be achieved will assist the CNSPC in addressing areas of the role that are not being realised. This also included the establishment of a link with academic departments. In conjunction with the PHN service the examination of a “shared plan of care”.

The aim of this study was to explore role evolvement and professional development in practice nursing in the UK. General practice is currently central to NHS reform, producing favourable conditions for the practice nurse role to strengthen and develop. However, the literature has continued to describe practice nurses as a disempowered, isolated group with many constraints reducing their ability to respond to opportunities. The rationale for conducting the study was therefore to provide a greater understanding about the constraining factors and their influence on practice nurses wishing to develop their role. The research was conducted in two parts; a survey to identify the range of issues and a case study to explore them in depth. A combination of factors was found to contribute to the way the practice nurse role evolves. These are education, practice culture, practice nurse personal characteristics and empowerment. Empowerment holds the key to maximising the conditions favourable to role evolvement. This is not however a „single‟ factor; it represents the combined synergistic effects of practice culture and practice nurse personal characteristics. The interrelationship between these was captured in a set of „empowering employment principles‟, which illustrate the features most conducive to role evolvement, providing a tool for nurses and their employers to enhance role development.

The interest of this thesis lies in examining hospital-based nurses' experiences of health promotion by enquiring into what they understand by the term and what their practice of it is. The research begins with a questionnaire survey in order to describe the nurses' attitudes, the health promotion activities they took part in and the influencing factors. The sample for the survey, all from one NHS hospital in Scotland, was a group of 244 nurses (47% response rate) from both medical and surgical wards in the hospital. Semi-structured interviews with 16 nurses were recorded to gather further data on the nurses' insights into their role in health promotion in the hospital. Role theory was employed to orient this study to analyse the nurses' role expectations, their behavioural patterns, and the environment of hospital nursing relevant to health promotion. The data were analysed using quantitative and qualitative methods as appropriate. The study finds that there is a distinct discrepancy between the nurses' role expectations and the actual experiences described in the nurses' accounts. The health promotion role as understood by the nurses appeared to be too theoretical and rhetorical to fit with their current practice of it. The finding also reveals that the health promotion role was composed of divergent patterns within nursing practice although the nurses were not aware of this. The discussion of this phenomenon focuses on three issues: the nurses' experiences of the discrepancy between the expected role and the actual practice, the relation between health promotion and nursing, and the duality of the health promotion role. These analyses are, in varying degrees, all concerned with the idealized and the actual of the health promotion role and what and how each of them impacts on nurses' experiences of health promotion in hospital. It suggests that health promotion is much more sophisticatedly interconnected with nursing in hospital than has been recognized. Ignoring the existence of the actual health promotion role, a radical shift in ideology and policy of health promotion may never be a good solution for expanding the nursing role since this may result in a distorted role expectation and in unnecessary emotional cost to nurses in hospital.

<b>Background</b>: ESRD is a serious and irreversible condition. Understanding the impact of ESRD and its treatment on an individual's QoL is important. There are limited studies found that assess QoL and Health-related QoL in Arab Muslim patients, and Oman in particular. <b>Method</b>: A cross-sectional, correlational study was conducted in four phases. Phase One explored the conceptual basis of QoL and how that has been assessed in ESRD patients. Phase Two explored the understanding and acceptability of the concepts within Omani patients using cognitive interviewing and individualised QoL instrument. Phase Three tested the feasibility of the main study design. Phase Four assessed the level and predictors of QoL/HRQoL from 13 haemodialysis units across Oman; and tested psychometric adequacy of key measures using exploratory and confirmatory factor analysis. <b>Findings</b>: Phase 1: showed inconsistencies and inappropriate us of the terms QoL and HRQoL in literature. A range of measures used to examine QoL/HRQoL. Phase 2: revealed some cultural sensitivities in two items of the SF36v2 and QoLI-D measures but generally were accepted. The SEIQoL-DW instrument supported the finding that QoL is a meaningful concept but one significant difference was the importance and universality of religion/spirituality as a key aspect of QoL. Phase 3: showed that chosen study approach was feasible and acceptable. Six nurses were identified and trained to support in patient recruitment and data collection. Phase 4: participants were 445 with mean age 46.59. Majority were male (56.3 %), married (62.5%), and employed (37.5%). Significant impairment in HRQoL was found for most of SF36v2 scales: PF 52.24, RP 54.24, BP 56.72, GH 53.18, VT 52.90, SF 60.50, RE 56.25, MH 63.75, respectively. Anxiety and depression symptoms were the most significant predictors and fatigue and pruritus were next. Also Muslims patients with ESRD encounter difficulties in performing their religion obligations due to the disease. Psychometric testing revealed that SF-36 is a three-factor structure with the inclusion of a separate role functioning component; and HADS one and two factor solutions were supported. <b>Conclusion</b>: future studies should continue to identify factors that influence quality of life and determine interventions that enhance a person’s sense of well-being.

Riyadh City in the Kingdom of Saudi Arabia (KSA) has a chronic and severe shortage of Saudi-trained nurses and a high nurse turnover rate. Expatriate nurses comprise most of the nursing workforce in Riyadh. This presents a challenge to safe healthcare delivery. To formulate strategies to promote and encourage secondary school Saudi students to choose nursing as their career path, it is imperative to understand community attitudes and perceptions toward the nursing profession. The aim of this study is to explore the perception of the Riyadh community toward nursing as a future career choice. In this study, the Riyadh community refers to final year high school students, parents of high school students and Saudi nationals working as nurses in Riyadh. A sequential exploratory mixed-method study was utilised to accomplish the aim and objectives of the study. The first phase uses qualitative focus groups and was conducted with the general community and nursing groups; it explored the issues and their perceptions of nursing in general. A questionnaire was adopted from Elham Al Naqshbandi. The validity and reliability of the questionnaire was tested, and the items of the questionnaire were assessed for their appropriateness. Finally, the questionnaire was distributed to the target sample in groups in Riyadh City. The qualitative findings were presented using explanatory themes in two sections. The three themes in section one are as follows: What is nursing? The contradictions; Social challenges; and Influence on the students’ decision to choose nursing as a career choice. The two themes in section two are the following: Experiences in career choice and a view of nursing in the Riyadh community. In the quantitative stage, 554 (86.6%) high school students completed the questionnaire in October 2014. The findings indicate that although school students respect the nursing profession, they demonstrated a lack of awareness in the community about nursing. Students’ concerns about nursing were around perceived future marital status and the lower financial remuneration compared to other professions. Riyadh community high school students are potential recruits for local nursing programmes and are a source of understanding about nursing as a career choice. The findings of this study support previous studies that reveal that choosing nursing as a career in Riyadh, KSA is strongly influenced by the societal image of the nursing profession and family attitude toward nursing. One’s perception of nursing as a career in Riyadh is influenced by institutional factors in the Saudi context (cultural-cognitive and normative factors). The reasons for not being interested in nursing as a future career include, but are not restricted to, normative factors; social status, financial status and sociocultural factors, such as influence of parents and religion; the issue of mixing with other genders; and long working hours and doing night shifts. Encouraging Saudi high school students to consider nursing as a future career option in Riyadh city requires fundamental reform and improvement to the societal image and understanding of the nursing profession. Strategies to do require plans to engage family members, particularly parents, as well as the leaders from high schools, nursing, the community, media and religious leaders to help reshape the image of nursing.

Over past centuries, childbirth has become increasingly medicalised, with a shift to hospital births and an overuse of interventions for women at low risk of childbirth complication. In response, there has been a move towards normalising birth which has grown in strength over recent years. In this thesis, I describe a programme of research which aimed to examine whether intrapartum birthing pool use could make an important contribution to normalising childbirth for low risk women. Maternity stakeholders differ in their views of intrapartum birthing pool use, with some emphasising its potential to reduce interventions and increase spontaneous birth and others raising concerns that birthing pool use, particularly waterbirth, predisposes women and their newborn to an increased risk of adverse events and outcomes The focus of my programme of research was therefore on examining the efficacy and safety of intrapartum birthing pool use, and its potential contribution to normalising childbirth for healthy women. In the first stage of my research programme, I analysed prospectively collected data for 8,924 nulliparous and multiparous women who used a birthing pool during labour in their planned place of birth. In the second stage ̧ I explored the possibility of comparing intrapartum interventions and outcomes for women who used a birthing pool and women who could have, but chose not to use a birthing pool in one obstetric unit. Having found the unit was not representative of other obstetric units, in the third stage I used a bespoke dataset comprising routinely collected maternity data collated by Hospital Episode Statistics (HES) as a comparator for the birthing pool data. This research found that, for the birthing pool sample, adverse maternal and newborn outcomes were rare, and there were no differences in interventions and outcomes between care settings for multiparae or newborn. Comparisons with HES data showed significantly more birthing pool women had a spontaneous birth. This allays concerns over safety and supports the conclusion that intrapartum birthing pool use can make an important contribution to normalising birth.

There is good evidence to suggest that nurses’ bias towards patients with obesity has adverse psychological and physical health implications for patients in terms of poorer care from healthcare staff and the avoidance of healthcare. Despite important clinical implications the literature yields no consensus about specific factors relating to weight bias and no consistently used theoretical framework to interpret findings. Therefore this study aimed to draw on intergroup theories of weight bias to explore the relationship between weight bias in nurses and their self-esteem, BMI, qualification status, stress and burnout. The study used a cross sectional mixed method design, involving an online survey using standardized weight bias, self-esteem, stress and burnout measures and an open ended question about bias. Participants were 218 undergraduate and postgraduate nurses practicing within the United Kingdom. There was no evidence of weight bias and hence limited correlations detected between weight bias and self-esteem, BMI, qualification status, stress and burnout. Analysis of the open-ended responses suggests that social identity may influence weight bias, and the conceptual frameworks that nurses use to make sense of obesity. The used of standardised measures to explore factors relating to weight bias did not add clarity to the literature. However, qualitative data in this study enabled a better understanding of the complexity of attitudes towards obesity. Attitudes are portrayed in the context of a hierarchy of complex social identities situated within a broader social context. The qualitative analysis revealed that both these issues may make it difficult for nurses to ‘own’ more negative attitudes, which may explain the inability of more restrictive survey design methodologies to reveal the complexity of attitudes within a social context. Future research that uses methodologies that enable exploration of the complexity around the nursing role may further enhance our understanding of weight bias in nurses.

BACKGROUND: Nursing is a moral practice that aims at the good of patients, families and communities (Gastmans, de Casterlé and Schotsmans, 1998). However, applying ethical principles in practice is not a problem-free enterprise (Lützén et al., 2003; Schluter et al., 2008; Epstein and Hamric, 2009; Epstein and Delgado, 2010) due to the particular position that nurses have within healthcare systems, institutions and care teams. Nevertheless, the majority of nurses continue to work ethically despite moral tensions and moral distress. One possibility is that the events that follow a morally distressing situation constitute a process of moral resilience. OBJECTIVES: This study aimed to examine the main concerns among intensive care nurses in respect of ethical practice, and to investigate how nurses continue to practise in an ethical way despite pressures, tensions and conflicts. Furthermore, this study aimed at developing an explanatory theory of the moral resilience process, understood as a basic social process, which follows a morally challenging situation. DESIGN: This is a qualitative study drawing on Glaser and Strauss’ (1967) version of grounded theory. The data for this study consisted in field notes and interviews from 16 nurses working in intensive care. In-depth interviews were carried out with open-ended questions. Data analysis followed the method suggested by Glaser and Strauss (1967) and Glaser (1978; 2005; 2011) using the constant comparative method. ETHICAL CONSIDERATIONS: The study was approved by the University Ethics Committee of the University of Surrey, UK, and by the Cantonal Ethics Committee and the Hospital Research Committee of the Southern Switzerland Hospital Organisation. Each participant signed an informed consent form. FINDINGS: This study breaks new ground in addressing intensive care nurses’ main concern regarding moral practice. Harmonising connectedness is both: nurses’ main concern and the patterns that characterise moral resilience CONCLUSIONS AND RECOMMENDATIONS: This study offers new insight into intensive care nurses’ moral life, moral wellbeing and strategies nurses put in place in order to achieve moral wellbeing. This study offers new perspectives that should be taken into consideration in nurses’ education and in demonstrating measures that aim to increase nurses’ moral resilience and their professional retention.

Background: Poor adherence to drug regimens is a major cause of uncontrolled blood pressure (BP) in people with hypertension. Aim: To evaluate the efficacy of adherence therapy (AT) compared to treatment as usual (TAU) in reducing BP in non-adherent hypertensive patients. Additionally, a qualitative study was conducted to understand and explore patient's experience of AT. Design: A single blind parallel group RCT was conducted between August 2009 and January 2010, in outpatient clinics in Jordan. Patients were assessed at baseline and at 11 weeks by blinded assessors. At 11 weeks semi-structured qualitative interviews were also performed. Method: One hundred and thirty six adult patients with a mean baseline BP of 165 mm Hg (sd 10) over 102 mm Hg (sd 7) were randomly assigned to receive either TAU or AT which consisted of seven weekly 20 minutes sessions. The primary outcome was systolic blood pressure (SBP). Semi-structured interviews were conducted with 10 patients who had received AT. Results: AT lowered SBP by-23 mm Hg (95% CI: -26, -20) and diastolic BP (DBP) by -15 mm Hg (95% CI: -18, -13), improved adherence by 37%, and improved their beliefs towards taking medication at 11 weeks compared to TAU. The thematic analysis of the interview transcripts identified five major themes of patient's experience of AT; modifying attitudes and beliefs, positive impact on self efficacy, motivational therapist, positive impact on wellbeing, and a well designed intervention. Conclusions: Adherence therapy changes patients' negative beliefs and attitude toward antihypertensive drugs and this increases their adherence to medication regimes which then leads to a clinically important reduction in BP. This reduction could be predicted to lead to reduced incidence of the adverse consequence of hypertension such as strokes, myocardial infarction, or death.

Background: Evidence suggest that for people living with cancer and dementia the exploration of memory loss is superficially based upon patient or carer disclosure. Patients tend to underplay the importance and extent of memory problems in cancer consultations and staff found assessment challenging, avoiding exploring memory without an obvious therapeutic gain. Compared to cancer patients without dementia, people treated for cancer with pre-existing dementia are diagnosed at a later or unknown stage, receiving less treatment with more treatment complications and poorer survival. This highlights the challenge for carers in advocating and negotiating treatment choices with their relative. Aim: To examine the challenges of informal carers supporting someone with cancer and dementia within the United Kingdom Methods: In depth interviews were conducted with 7 informal carers using a narrative approach to examine the construction of their experiences. Recruitment took place at a Psycho-oncology unit at a tertiary cancer centre in the north west of England between July 2014-March 2015. Two participants were recruited external to the NHS through snowballing techniques. Both NHS and University ethical approval was obtained. Results: The findings demonstrate how informal carers navigate a path through complex cancer treatments and support their relative. A cancer diagnosis often requires multiple treatment visits to an oncology centre and this can be challenging for carers. They find that they need to co-ordinate and manage both health professionals and their care recipient(s) in terms of getting access to appropriate services and support. This process can be particularly challenging in the presence of a cognitive impairment that often demands effective communication with different agencies. Carers frequently experienced multiple challenges include dealing with the stigma that is characteristic of the dementia experience and the added complexity of negotiating this within a cancer care context. Issues of decision-making, best interests and quality of life were also of central concern for carers. Conclusions: Carers within this particular context face complex challenges that are not necessarily obvious and appear under reported. Their role is often rendered invisible by the nature of the care recipients’ condition. We suggest health professionals need to respond to and support carers in different ways that do not stigmatise and hence discriminate against them.