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Rationale: Clinical supervision has often been identified as good practice, and a means of enhancing patient care, although there is a limited evidence base. This research investigates whether clinical supervision groups in primary care are effective. Aim and objectives: The aim of this study is to identify whether clinical supervision groups in primary care settings are effective in comparison with the literature and evidence. The objectives are to investigate whether group clinical supervision corresponds with Proctor's (1986) model. Secondly to identify characteristics of the supervisor which supervisees and supervisors prioritised. The third objective is whether clinical supervision groups place differing demands on the supervisor than individual clinical supervision, and to make any recommendations which the research identified. Methodology: A mixed-methods, three-phased approach was used. In Phase-I postal questionnaires were used to gather background information on staff who participated in clinical supervision groups. The second phase involved non-participant observations of two clinical supervision sessions each of three different groups. While in Phase-3 focus groups were carried out with two clinical supervision groups. Results: The participants in the research benefited most from clinical supervision which was predominantly restorative in accordance with Proctor's (1986) model. The supervisors lacked the skills necessary to manage clinical supervision groups. Both supervisees and supervisors regarded approachability and support as the most valued characteristics of the supervisor. While the supervisees valued the supervisors' knowledge more than the supervisors, who felt this was a characteristic which they lacked and did not prioritize. Conclusion: A model of clinical supervision is required focusing on the needs of more experienced practitioners. Clinical supervision of groups requires skills and training in clinical supervision and in managing groups.

There is a paucity of literature around 'conditioning' processes prior to boundary transgressions. This study aims to explore how 'conditioning' processes are understood by nurses working with patients in forensic settings, as a precedent to boundary crossings. Design A repertory grid interview technique was used to explore nurses' implicit constructs around the topic of' conditioning'. A content analysis was performed on the grid data set, using participants' ratings, to gain a preliminary understanding of nurses' constructs. A thematic analysis was conducted on the transcripts of the grid interviews, to understand how these constructs were discussed more broadly. Participants Eleven mental health nurses with over one year's experience of working in forensic settings, including medium secure units, were recruited from two forensic services. Results Content analysis of the grids identified 11 categories associated with nurses feeling influenced to cross boundaries. These included having a strong, positive regard for the patient and a lack of awareness for the consequences of the decision. These ideas were further supported by six key themes which emerged from the thematic analysis: 1) Level of decision-making 2) Viewing the patient as a 'person' 3) Over-familiarity 4) Personal identity roles 5) Team cohesiveness 6) Awareness of patients' intentions as inhibiting transgressions. Implications Nurses appeared to draw on internal, unconscious processes, rather than motivated actions of the patient towards them, when crossing boundaries. The implications of these findings and applications to Clinical Psychology are discussed, as well as implications for future research.

This thesis evolves around the identification and analysis of the particular sociotechnical factors and conditions that facilitate the implementation of new information and communication technologies (lCT) in complex clinical settings. Today most national health systems around the world link the need for best healthcare provision with the overall efficiency of their institutions. Such orientations undoubtedly require outcomes linked to lCTs so as to assign them with criteria and measures of success. On the other hand, implementations of such technologies in healthcare organisations, particularly under the Connecting for Health (CfH) IT programme, have not been equally successful. As science and technology studies (STS) scholarship shows, these technologies, despite their technical robustness, do not guarantee successful implementations. It is rather the intertwining of people, machines and spaces at the local setting that determines the fate of the new system. The four-hour waiting target (now a standard of hospital performance) for patients attending an Accident & Emergency Department (A&E) has undoubtedly become the most important catalyst of effective change towards a "whole system" approach in the provision of unscheduled care. This is, partially, because waiting times in A&Es have been acknowledged as one of the most prominent causes of dissatisfaction for patients interacting with the National Health Service (NHS). From the mid-1990s, Conservative and Labour, governments in the UK have developed and implemented a series of reform programmes to address this issue. After a long series of negotiations, which were intensified at the dawn of the new century, the Department of Health (DH), in accordance with the recommendations of relevant emergency clinical bodies and patient advocacy groups, stabilised, in 2004, the target (now a standard of hospital performance) to 98% of patients attending A&Es to be treated and admitted or discharged within four hours. During that time the DH also released a report with key recommendations on building layouts for these 3 hospital departments in order to positively influence efficient patient care by appropriating circulation spaces for patients, clinicians and visitors. This thesis uses a case study of the implementation of a clinical information system for patient registration and tracking in the busy emergency department of a large Acute Care University Trust in the East Midlands, UK. It explores the complexity of relations and subsequent negotiations between these heterogeneous elements during the formation of a new practice ordering for nursing work. For this, I draw on the work of ANT research, firstly, within the broad field of geography. I conceptualise space and time as invaluable non-human entities that need to be enrolled and converged at the local level in order for the inhabitants (clinicians, administrators, managers) and the visitors (patients and their carers) of this temporal network to enact prescribed movements, interactions, communications and relationships. From there, this thesis examines the way the above national policies (i.e. waiting time targets, built environment design) have come to facilitate the introduction, and subsequent stabilisation, of a clinical lCT in the local clinical setting. Based on the findings from the analysis of 30 semi-structured interviews with nurses, the change manager, the system administrator and assistants as well as from relevant policy documents, internal reports, building blueprints and implementation studies, I argue that the re-engineering of healthcare practice with the diffusion of a new technology is not a fixed and linear process, but more of an interplay of various fluctuant, performative and eo-constitutive technical and social factors. In particular, I first show that the DH strategically attempted at ordering the A&E towards specific outcomes of performativity by formalising procedures, interactions and generally the behaviours of these peripheral networks. Rooms and corridors were redesigned and timestamps are now being applied to every process so as to effect a new spatio-temporality in the planned circulation of patients and hospital staff in the A&E department. As a result, groups of users are being integrated or segregated according to particular (and rationalistic) conceptions of patient flows. 4 For the above purposes, the specific technology under examination arrives in the A&E as an efficient technological solution to a given waiting time problem. While issues of computer literacy and interaction with complex technologies remained a concern for the nursing staff during the implementation phase, these were substantially downgraded in the face of a new rigid policy which aimed at addressing one of the most prominent causes of patient dissatisfaction. The technology was gradually translated and transformed into an invaluable ally. Conversely, success includes not only the appropriate use of the system, but also the users' high dependence on it and finally the network's ability to act as a platform for continual, technologically mediated, reformation of its practices under specific strategic policies. Through an ANT conceptualisation, the thesis concludes by arguing that despite the various negotiations that take part between the centre of calculation (DH) and the local setting (A&E) offering, to the latter, some room for manoeuvre and discretion, in the end, the former is constantly enhancing its instrumental and obligatory passage role in shaping local action. It does this by strategically organising the opening of the black-box of its constituted healthcare institutions through the enrolment, the re-skilling and, after that, the mobilisation of specific intra-organisational networks. 5.

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Aim: To discover how male students of nursing in Wales, articulate how they learn in the college pre-registration nursing environment Epistemological framework: The language of hegemony, hegemonic masculinity, complicity, marginalization and subordination from ConnelFs (1995) masculinities framework was revised to create what is called Ryan's model, which guided this study. Ryan's model was developed pre-analysis and post analysis. Pre-analysis, hegemony was interpreted as 'dominance and male positioning' and post analysis became "dominance reduced/ mutual and neutral appreciation of nursing undergraduate peers'. Pre-analysis hegemonic masculinity was interpreted as 4Men: their gendered practice in society' and post analysis 4Men: their gendered practice in undergraduate nursing'. Pre-analysis - complicity was termed as hidden maleness and post analysis 'Maleness surfaces through the articulation of learning needs and demonstration of their learning'. Pre-analysis marginalization was interpreted as 'Imposed feelings of marginalization on learning opportunities' and post analysis 'Exclusion and being excluded feelings of inferiority when learning and visualising procedures in clinical practice. In the pre-analysis, Subordination was interpreted as "gendered subordination' and post analysis as scenarios that captured the principles behind the 'in and out groups' and scenarios 'looking at inferior and superior knowledge'. The main ethos that gender is socially constructed connects to the analytical approach of Charmaz (2006). Methodology and methods: Thirteen participants took part in the two pilot studies and eleven in the main study. The research data consisted of tape recorded speech from focus groups and individual interviews. The analysis of fieldnotes contributed to triangulation. The aim was to develop a grounded theory based on how male students articulated how they learnt in the classroom and in clinical practice. Their implicit actions and speech were analysed using the contructivist grounded theory approach by Charmaz. Results: Four categories, along with a core category were developed. The core category, Voice: never hidden, released by masculinity captured the essence of the four categories. The act of coming together allowed a vocal space to discuss learning and how they see themselves in relation to the numerically dominant group. The male students retained their socially perceived masculinity by being able to voice how they learn through the dominance of their speech. Relationships within the classroom were de-gendered and a small number of participants assumed a neutral identity, 'the student nurse'. Limited opportunities resulted through discriminatory attitudes and the disability of dyslexia. Conclusion: The findings of this study suggested hegemonic masculinity was rarely practised through the medium of voice, but male students could openly call on the complicit nature of masculinity to voice how they learnt in college and in the clinical area. Their preferred route to acquire skills was through the visual route however, even the complicit nature of masculinity could not triumph in clinical practice to achieve learning with regards intimate care. Overall, the male student of nursing possesses masculinity, which is conducive with the nature of nursing and a sound ability to voice how they learn.

This research explores the role and value of nurse practitioners to UK general practice from the perspective of nurses working in these advanced roles. Nursing has had a presence in general practice for decades, but it is only over the last twenty years that it has extended into a traditional medical domain of care and treatment. Research has understandably focused on the ability of nurses to substitute for doctors and there has been relatively little investigation of what nursing at an advanced level contributes. The study is located within a qualitative interpretive paradigm utilising a Social Constructionist (SC) approach which recognises that knowledge is not based solely on objective observations of the world, but is generated between individuals in the course of their everyday life. The theoretical perspective grounded in this epistemological paradigm is symbolic interactionism (SI). This emphasises the construction of the social world and meaning through the use of symbols, particularly language. Thematic Analysis (TA) is utilised deliberately as a research strategy guiding sampling, data generation, collection and analysis. A purposive sample of ten nurse practitioners was selected. Semi-structured interviews were conducted, digitally recorded, transcribed and the data analysed using Braun and Clarke’s model. Four broad themes were identified from the narratives; the enactment and development of the nurse practitioner role, its value to the organisation and function of general practice, the impact of nurse consultation upon the patient experience and finally, how the role has integrated into the primary health care team. The findings demonstrate that rather than one generic nurse practitioner role in general practice there are multiple constructs, driven at macro level by political necessity, negotiated at micro level by the needs of individual general practices and framed within a professional vacuum of non-regulation. This has not been fully explained before. The research provides a clear and original understanding of what nurse practitioners can contribute to general practice through the diversification of their roles, not as substitute but as part of a diverse, fluid team working collaboratively to address the needs of the general practice population.