Tracheostomy is one of the first recorded surgical procedures and refers to an incision into the windpipe at the front of the neck, classically performed by surgeons to relieve airway obstruction. A tracheostomy tube can be inserted to maintain airway patency. The majority of tracheostomies are now performed the critically ill, typically whilst dependent on invasive respiratory support. Analysis of tracheostomy-related critical incidents helped to understand the frequency, nature and severity of problems that can occur at initial placement or during subsequent use. If problems occur, significant harm may rapidly develop, especially in the critically ill. Recurrent themes that contributed to avoidable mortality include poor emergency management and limitations in infrastructure, equipment provision, staff training and education. Many of the problems identified are amenable to prospective, multidisciplinary quality improvement strategies. This thesis describes my published work in this area. An underlying challenge to improving care lies in the fact that care requires input from many clinical disciplines. Complex patients need care in specialised settings that are not always adequately trained and supported in delivering safe tracheostomy care. My research has evaluated the impact of a co-ordinated multidisciplinary approach using bespoke resources, staff education, infrastructure changes and patient champions to direct healthcare improvements. I have critically appraised my bespoke resources and evaluated and justified the use of a variety of quality and safety metrics to define better care, both at patient-level and using institutional process measures, reflecting better coordination of care, contributing to significant cost savings. Further opportunities to build understanding of the nature of tracheostomy problems in ICU and the success of quality improvement initiatives will be discussed. Future aims are to not only improve care but also to perform a detailed economic analysis and capture knowledge on how to best implement necessary changes rapidly in today’s complex NHS.

This PhD by Published Work (Route 2) thesis is comprised of a collection of significant papers I have published with co-authors between the years of 2010 and 2017. These published works are supported by supplemental papers, abstracts, and conference proceedings and comprise a body of work that has sought to understand how surgical education is carried out in surgical residency programs, with particular interest in learning about how surgical educators teach, how surgical trainees perceive the teaching they receive, the creation, use, and evaluation of new tools for surgical education, and the development of new surgical training curricula in an era of competency-based medical education. My research began out of a need to evaluate the problem of a lack of formal guidelines and direction to aid surgical educators in the development, delivery, and evaluation of competency-based residency education programs throughout Canada. Without formal guidelines driving curricula development, surgical trainees could potentially be graduating at different levels of proficiency, which is problematic. In addition to existing standardised testing procedures, other surgical education researchers and I believe that residents must also be evaluated via ongoing thorough assessments of their level of competency when performing in the high stakes environment of the operating room. The Royal College of Physicians and Surgeons of Canada (RCPSC) is well-known for their Canadian Medical Education Directives for Specialists (CanMEDS) physician competency framework, which has been adopted by medical and surgical training programs worldwide. In its most recent CanMEDS iteration (2015), the RCPSC has released a new initiative called Competence by Design (CBD), which will affect all Canadian residency programs. The primary goal of this initiative is to completely remove the time element of residency training and focus on residents’ progression through their respective programs solely based on the passing of pre-defined competency “milestones”. This will cause a paradigm shift whereby the traditional apprenticeship model long-used in surgical teaching may eventually cease to exist. With this thesis, I have included papers that have focused on surgical education within competency-based frameworks and means by which to optimise curricula for surgical training. My research began with the exploratory work around how surgical educators teach and how trainees perceive they are taught, and is followed by a description of simulation and the development of new tools for surgical simulation and training. I then describe the development of new curricula that are focused on competency-based initiatives and can be used to begin the development of residency curricula for CBD. This research is timely, as many accrediting bodies worldwide are currently in the process of adopting and developing competency-based curricula at different training levels. The research presented in this thesis significantly contributes to the existing body of surgical education research, and future work, some of which is described, will focus on expanding the reach of our research initiatives via collaborative efforts with other surgical residency programs within Canada and also abroad.

This thesis presents a qualitative research study, which identifies issues regarding the development of palliative care in the Kingdom of Saudi Arabia (KSA) hospital setting, from the perceptions of healthcare professionals working in Saudi Arabian hospitals. The literature suggests that challenges to palliative care in KSA exist on various levels. At the professional level, they exist where healthcare practitioners may neither be sufficiently equipped nor sufficiently oriented to deal with palliative care concerns. Saudi practitioners may have misconceptions that lead them to recommend or carry out activities that may be detrimental to the palliative care of their patient. Issues also exist at institutional levels, where palliative care systems in place in Saudi hospitals are insufficient for addressing the needs of its patients. There are also issues found at the cultural and legal levels, where pain and individual choice are not considered sufficiently important in Islamic law especially when weighed against matters about prolonging and preserving life and preparing the individual for the afterlife. The aims of this study were to determine the perceptions of KSA hospital healthcare professionals regarding palliative care, identify issues regarding the development of palliative care in the KSA hospital setting and to develop recommendations for strengthening the value of palliative care among healthcare professionals in KSA. To this end, semi-structured qualitative interviews were carried out with members of staff working in hospitals in KSA, with terminally ill patients. The findings suggest that while some participants define palliative care in a way which is in keeping with internationally recognised definitions, others had not heard of the term, or defined it in a way which was incomplete. Insights are provided in to doctors and nurses experiences of palliative care, an example of which is that the personality of the healthcare provided was a significant factor in the quality of palliative care. The findings suggested that as a specialism, palliative care is seen as unique and growing, and participants understood the need and importance of this area. Issues and problems with palliative care were identified, including issues with communication and lack of material and human resources. Various opinions were offered as to the role of the media in promoting palliative care in KSA, issues with medication, including access and procedures, were discussed, and finally the participants spoke about their vision of the future of palliative care in KSA, and what would be needed to achieve this vision. The contribution of the present study to the understanding of the perceptions of healthcare workers in KSA towards palliative care is significant considering the scarcity of research in this area, particularly qualitative research. It supports the findings of previous research into palliative care in KSA and the wider research on palliative care. It also provides a unique insight into the views of healthcare workers in an Islamic culture, expanding upon current literature.

This research study set out to explore service-users' understanding about what they required in terms of cultural care from nurses. Situated within an interpretive paradigm, the choices made within the methodology were influenced by the writings of Hans-Georg Gadamer around dialogue and understanding. This approach facilitated a newer understanding to explore existing nursing knowledge around culturally appropriate care for a multicultural and diverse society. Having gained the appropriate ethical approval, participants were recruited from the five main ethnic groups that represented the population of Greater Manchester: White Majority, White Minority, South Asian, African-Caribbean and Chinese/Oriental. Twenty-one participants were interviewed, using a semi-structured approach. Utilising Attride-Stirling's (2001) Thematic Network analysis, all the transcriptions were analysed to develop Basic, Organising and Global Themes, to systematise the findings and discuss the rich data that emerged. Unexpectedly, during the interviews participants from the Majority population and the Black, Asian and Minority Ethnic participants expressed similar needs from culturally appropriate nursing care. Specifically, what service users needed from culturally appropriate care was linked to issues around how nurses communicated inter-culturally and the influence of intersectional processes, rather than addressing different, culturally specific needs. The participants stressed the need for nurses to utilise an individualised and non-ethnocentric manner as part of their intercultural communication and congruent interpersonal skills. In order to fulfil this in a fair and compassionate way, nurses would need to develop an openness and genuine desire to engage service users in intercultural communication, and be ready to listen, enable and be curious to learn about their story.

Background: Preeclampsia (PE) affects 2-3% of all pregnancies and is a major cause of maternal and perinatal morbidity and mortality. The current approach to screening for PE is based on the identification of risk factors from maternal characteristics and medical history. This approach, however, fails to identify a high proportion of cases of PE and does not provide individualised, patient-specific results. An alternative approach is to combine maternal factors with biophysical and biochemical markers to estimate the individual probability of developing PE with higher detection rates. To date, no intervention is proven to reduce the risk of the disease, and several studies evaluating the use of aspirin for prevention of PE led to inconclusive results. Objectives: The aims of the studies included in this thesis are, first, to prospectively validate in a large European population a first-trimester algorithm for prediction of PE that combines maternal demographic characteristics and medical history with biophysical and biochemical markers; second, to compare this method of screening to the performance of currently used guidelines; third, to evaluate a possible beneficial effect of aspirin initiated at 11 to 14 weeks of gestation and at a dose of 150 mg in the prevention of PE in a multicentre, double-blind, placebo-controlled randomised trial; and fourth, to analyse a potential role of cell-free DNA testing in the prediction of PE. Methods: Combined screening for PE was applied in the first or second trimester, and women found to be at high-risk in the first trimester were offered participation in a double-blind trial of aspirin against placebo in six European countries. We have recorded maternal characteristics and history, measured the uterine artery pulsatility index (UtPI) on ultrasound, the mean arterial pressure (MAP), serum concentration of pregnancy-associated plasma protein A (PAPP-A) and placental growth factor (PLGF). Pregnancy outcomes were obtained from the hospital maternity records. Bayes theorem was used to combine the a priori risk from maternal factors with the results of biomarker measurements and estimate individual probabilities. In the randomised trial, the analysis was performed in an intention-to-treat basis and the treatment effect on the primary outcome (the development of PE with delivery before 37 weeks of gestation) was reported with 95% confidence interval (CI), and on secondary outcomes with 99% CI. Cell-free DNA fetal fraction was compared with other first trimester markers for PE and in a case-control study. Results: Detection rates of combined screening, for a false-positive rate (FPR) of 10%, were 89% (95% CI 79-96%), 75% (95% CI 70-80%) and 47% (95% CI 44- 51%) for PE < 32 weeks, preterm PE and term disease, respectively. The performance of combined screening was superior to methods based on risk factors alone, both in the first and second trimesters. The use of aspirin by high-risk women reduced the incidence of preterm PE by 62% (adjusted odds ratio 0.38, 95% CI 0.20- 0.74). Secondary analyses have shown that the effect of aspirin was influenced by the level of compliance to treatment and was consistent in different subgroups according to maternal characteristics and obstetric history, but there was no evidence of beneficial effect of aspirin in women with chronic hypertension. Aspirin reduces the length of stay in NICU and costs through a reduction in premature births before 32 weeks due to PE. Fetal fraction on cell-free DNA testing correlates with other first trimester markers, but its role in screening for PE is uncertain. Conclusions: This thesis has demonstrated that combined screening for PE is superior to current guidelines based on maternal characteristics and history alone, and that aspirin, at a daily dose of 150 mg and given to high-risk patients from 11 to 14 weeks until 36 weeks of gestation, reduces the incidence preterm PE and the length of stay in NICU. The effect of the medication depends on good adherence to treatment and is questionable in patients with chronic hypertension.

This thesis is the result of a two-year participatory action research study that led to a radical change in the way critical care nurse education is delivered in Greater Manchester. It was motivated by concerns that poor academic performance by degree and master's students was reflective of a teaching 'ecology' (Kemmis et al., 2014) focused on sharing tacit specialist technical knowledge, rather than developing higher order thinking skills. The use of teaching strategies that support the development of these skills is important not only to academic improvement but also to clinical practice, where critical care nurses routinely critically analyse a large volume of data during decision making (Lyte, 2008). Methodology: Action Research (using mixed methods) • Focus groups and questionnaires explored the views of all students (n=250), Practice based educators (n=11), lead nurses (n=10), managers (2), university link lecturers (n=2). • Classroom observations evaluated teaching methods and content over the two-year study, measuring how well they were aligned to programme learning outcomes (n=24). Results • Classroom observations identified lectures lacked pathophysiology, evidence-based theory and contained little consideration of patient-centred 'nursing' care. • In contrast, students prioritised learning pathophysiology, the evidence-base underpinning clinical decisions and preferred teaching methods that enabled them to work with peers to apply theory directly to the context of clinical practice. • PBEs and students discovered new ways of teaching and learning. • Critical care nurse education was separated from acute care nurse education. Impact The findings changed local education provision, leading to the introduction of a new local critical care programme which commenced in September 2016. Critical care nurse education was refocused away from a technical, medical model towards one that provides opportunities for students to spend time in the classroom thinking like nurses to develop evidence based patient centred humane care solutions. The findings highlighted the value of academia, identified the usefulness of formative assignments and informed the development of new and innovative assessment strategies. The interventions corresponded with significant improvements in student academic performance and clinical confidence, which had a positive impact on care delivery. The findings informed the development of the National Standards for Adult Critical Care Nurse Education, which were published in 2016 (CC3N, 2016). Conclusion Nurse education needs to evolve to meet the changing needs of students and practice. A tripartite approach involving academics, clinical practice and students working together, was highly effective in reshaping both local and national critical care nurse education.

This study investigated how dyslexia affected qualified nurses’ lifelong learning and how they engaged in professional development; a requirement of registration. It considered the educational and professional experiences of nurses and lecturers who had supported registered nurses with dyslexia. A qualitative, in-depth, narrative lifecourse approach was used with participants across Great Britain. The initial study informed the conduct of the main study and interview questions. The main study involved fourteen registered nurses and nine lecturers recruited purposefully through posters and Twitter. Semi-structured interviews were conducted either face-to-face, by telephone or using Skype. Data were analysed using template analysis and validated by the participants using asynchronous online discussion forums. The analysis of the data identified that dyslexia affected nurses in their professional capacity, as well as affecting their learning. The findings further identified how nurses developed compensatory strategies both personally and in practice seeking to overcome negative learning experiences. Transitions were particularly problematic, either between academic levels or practice areas. Disclosure of dyslexia was dependent on supportive relationships. However, patient safety was seen as paramount. Lecturers recognised that early identification of dyslexia was important to enable appropriate support and reasonable adjustments, but is dependent on recognition of dyslexia. The findings of the nurses’ and lecturers’ data were used to develop a conceptual framework to illustrate how both personal and professional development overlap but are also influenced by psychological and social factors. Recommendations from the study note that professional development is required for lecturers to ensure early recognition and support for nurses with dyslexia, along with early formative assessment of written work at university. However, education beyond initial training also needs to take account of the personal impacts of dyslexia and the effects of transitions should be factored into inclusive assessment strategies and support available.

Aims and objectives: The aim of this study was to explore health care assistants' (HCAs) role and influence on student nurses' clinical learning experience. Objectives induded the identification of pertinent issues relating to HCAs and students' learning in the clinical environment; the exploration of the differences and similarities of the work student nurses and HeA, their perceptions and experiences of roles and the identification of the impact of the HCAs role on the quality of student's clinical learning. Theoretical framework: To understand the relationship between HCA's and student nurses a symbolic interactionist framework was adopted, which is concerned with how people define and redefine themselves and their situation. Method: A three phased sequential exploratory mixed method research design was used, which involved a combination of prioritised qualitative and quantitative research approaches. In the first phase focus groups and interviews were undertaken witb 45 purposively selected student nurses whilst a questionnaire was disseminated in phase two to 439 students from both adult and mental health branch. The final phase involved oneto- one semi-structured interviews witb a III HCAs across private and public clinical settings. Results from the first analysis were used to inform the second phase of data collection and similarly, results from the second analysis were used to inform the third phase of data collection. Results: The study findings have provided an in sight into a range of contextual issues that influence the interactions and relationship between HCAs and student nurses which have a positive and negative influence on clinical learning experience and roles. Results demonstrate that HCAs playa major part in the education of student nurses with regards basic, clinical, and non-clinical tasks, with and without the approval of registered staff. Their participation was justified based on mentor unavailability, their closeness to the student and the patient. Conclusion: Mechanisms of workforce planning need to pay particular attention to the expanding role of assistants as it has the potential to alter patterns of work and affect current educational approaches.

Background: Pregnancy is a major life event and the loss of pregnancy is an event with potential for adverse psychological outcomes. Although the understanding of grief after perinatal loss has progressed, there has been relatively little work specifically addressing the loss after miscarriage and termination of pregnancy due to fetal anomaly. Objectives: This study aimed to gain an understanding of experiences of miscarriage and termination of pregnancy for fetal anomaly among a group of Thai women Study design: An interpretive phenomenology approach was taken using unstructured interviews with 12 women who had undergone termination of pregnancy for fetal anomaly and 11 women who had experienced miscarriage in Chiang Mai province, Thailand. To gain the perspective of care the women received in the hospital, focus groups with 10 doctors and 10 nurse-midwives were conducted. Results: The data were analysed and interpreted using an Interpretative Phenomenological Analysis. The loss of hope is the essence of the women’s experiences of miscarriage and therapeutic termination. Three themes emerged from both groups: 1) facing the loss of hope, 2) gaining emotional balance, and 3) the need for intervention. Although the main findings are similar, significant difference between them is the context of pregnancy loss. While miscarriage is an inevitable event and needs urgent treatment, the diagnosis of fetal anomaly leads the women to have a feeling of ambivalence around the decision to terminate the pregnancy. Conclusions: This study reinforces the difficulties that women have from the traumatic events of miscarriage and termination of pregnancy for fetal anomaly. The women need more in-depth knowledge and empathetic care from health professionals. Involving family members to support women in the labour unit can reduce the feelings of loneliness and insecurity. Recommendations: Health care professionals need to be educated to provide emotionally sensitive support for these women.

The work presented here is for the degree of PhD by publication. I have selected seven papers for consideration, published in high quality academic journals between 2002 and 2011. I am the lead author on four papers and joint author on three. These papers derive from projects undertaken during my fifteen year research career at the School for Health and Related Research (ScHARR), University of Sheffield. Whilst the services I evaluated varied in scope, my research forms a coherent body of work informing the evidence base on policy driven initiatives implemented within emergency and urgent care. I have contributed to the evidence base around three key aspects of evaluation: acceptability (patient, carer, and workforce), effectiveness, and equity with respect to three of the most significant recent changes within emergency and urgent healthcare in England: telephone delivered healthcare, new roles within the workforce and, extended access and patient choice. Specifically, I have identified: • Telephone delivered healthcare did not significantly change demand for services: patient reported data suggested that NHS Direct was ineffective in reducing demand for other health services across the whole system of emergency and urgent care. • Inequity in the use of new telephone triage services: those from poorer socioeconomic groups or with communication difficulties were less likely to have used NHS Direct than other groups. • Problems with acceptability within a newly established workforce: although the majority of NHS Direct nurses were satisfied with this new way of working, a minority of staff found the work to be monotonous, posing a challenge to the retention of staff. • Clinical effectiveness of new roles within the workforce: a community based service utilising paramedics with extended skills demonstrated that paramedics can be trained to safely assess and treat older people with minor conditions which in turn led to a reduction in the need for attendance at an emergency department. • Patient and carer acceptability of new roles within the workforce: whilst minor acute health episodes do impact on patients and carers, initiatives such as utilising paramedics with extended skills in the community have a positive impact on the lives of these groups. Indeed, both groups reported high levels of satisfaction, and carers reported needing to provide less input with physical caring activities as a result of this new role being implemented. • Where patients choose to seek care and their satisfaction with this care during an emergency and urgent care episode: the majority of patients use multiple services on their care pathway, a daytime GP as their access point to emergency and urgent care, and are satisfied with their overall care during an episode. My work has demonstrated both the strengths and limitations of the policy related initiatives which I have evaluated. In particular my evidence regarding NHS Direct indicated some limitations regarding this telephone based service. Policymakers must take note of this given their plans for the national roll out of the non-emergency healthcare telephone service ‘NHS 111’, and if the telephone is considered as the medium for a single point of access to emergency and urgent care in the future. In contrast, the evidence that I have provided regarding paramedics with extended skills was overwhelmingly positive. Policymakers should support, and commissioners should explore, this model of service delivery when considering how to utilise emergency care practitioners within a locality. As policymakers continue to move forward with a vision for integrated emergency and urgent care healthcare attention must be directed towards the potential impact this has on users of the emergency and urgent care system.