Background Research into the structural empowerment of nurse leaders (matrons, sisters / charge nurses, senior staff nurses) in middle management positions is of importance, as it is they who set an example to their teams and attempt to overcome barriers and maximise facilitators to high quality care and patient safety. A theoretical framework developed by Kanter (1977, 1993) established that opportunity, power and proportion are key determinants of structural empowerment in organisations. Few quantitative studies conducted in acute healthcare settings have investigated empowerment in nurse leaders and none have explored potential differences between unit leaders (matrons, sisters / charge nurses) and senior staff nurses. Qualitative exploration of the nature of empowerment is these groups is also lacking. Method The aim of this study was to investigate the level and nature of nurse leader empowerment in a large NHS Foundation Trust. A mixed methods design was implemented in four phases conducted over a 3 year period. In phase 1 the Conditions of Work Effectiveness Questionnaire II (CWEQII) was distributed to the total population (n=517) of nurse leaders achieving a response rate of 44.1% (n=228), of whom 35.9% (n=102) were senior staff nurses and 54.1% (n=126) unit leaders. In phases 2 and 3 semi-structured interviews were conducted with senior nurse managers (n=16) and a purposive sample of nurse leaders (n=21) who had completed the CWEQII. In phase 4, a documentary analysis was completed to support the identification and contextualisation of the organisational culture of the Trust. Quantitative data was entered into SPSS and analysed using descriptive and inferential statistics; qualitative data was analysed thematically. Results Across the study population a mean total empowerment score of 20.32 (SD 3.23) indicated a moderately high level of empowerment. No significant differences were found between senior staff nurses and unit leaders for total or global empowerment scores. Significant differences between groups were identified for information scores and those for selected components of informal power and support. Groups did not differ significantly on the sub-scores and components of opportunity, formal power and global empowerment. Qualitative analysis identified four core themes and eleven sub-themes relating to the nature of nurse leader empowerment. Nurture and advocacy were vital aspects of support and development in empowering junior colleagues. Use of the term influence was preferred to that of power. Disempowering aspects of organisational culture included hierarchies, tight control and outcome drivers created by the pressure to maintain status, achieve targets and risk aversion. Positive, empowering aspects of culture were related to leadership behaviours; role modelling, credibility, collaborative team working and communication, beneficence and respect for opinions, passion, motivation and enthusiasm. Conclusions Study findings have extended current knowledge on the level and nature of nurse leader empowerment and confirm that this is a complex, multi-faceted concept. In the single organisational setting of a high performing NHS Foundation Trust, integrated findings demonstrated the influence and inter-relationships of role responsibilities and hierarchical position, organisational constraints and cultural factors on organisational structural empowerment. Findings have contributed to further development of Kanter’s theoretical framework and have identified areas for further research, professional practice and service.

No description available.

There is a growing recognition that a better understanding of the heterogeneity of motives and determinants of labour market choices is needed to inform policies intended to redress current maldistribution of health workers, particularly in developing countries. This thesis explored the influence of altruism and other individual characteristics on nurses' job preferences in South Africa, to investigate the impact of potential policy interventions designed to attract nurses to under-served areas. Primary data collection was carried out with a sample of 377 nurses. First, measures of altruism were constructed by playing the dictator game, a behavioural economic game. The nurses showed greater altruism than is usually seen in such experiments, suggesting that more altruistic individuals self-select into the nursing profession. Since actual choices could not be observed, a labelled choice experiment was then used to reproduce the job opportunities offered to nurses at the beginning of their career. In the analysis of nurses' job preferences, a positive correlation was found between pro-social values and preferences for public jobs, while individuals from rural backgrounds were more likely to prefer rural jobs. Another choice experiment was used to model the effects of potential policy levers to make rural public jobs more attractive. The analysis showed that packages including monetary incentives were often the most powerful, and it confirmed the preferences of nurses from rural backgrounds. Combining the two choice experiments, a Markov model was constructed to predict the long-term effects of different policies on nurses' distribution in the labour market. Building on these outcomes, a cost-effectiveness model compares the effectiveness of several intervention packages to attract nurses to rural areas. This analysis showed that monetary incentives are never cost-effective, unlike education opportunities and the selection of more individuals who were more likely to prefer rural areas, such as people of rural origins.

No description available.

No description available.

Nurses and doctors work together in hospitals as they provide care to patients. Nursing knowledge and practice are affected by relationships between nurses and doctors. This study sought to shed light on relationships between nurses and doctors using a broad comparative approach. Relationships between nurses and doctors in Britain and America were examined in order to shed light on the nature of the relationship between nursing and medicine in Britain and America between 1860 and 1914 and to elucidate factors which contributed to the development of this relationship. Examination of the historical roots of the relationship between nursing and medicine may help nurses to develop a deeper understanding of the situation of nursing within healthcare and the ways in which historical factors, such as societal practices and assumptions regarding class, gender, hospitals, and work have affected nursing theory, practice, and status. Studying these issues in two countries may facilitate exposure of factors which might be overlooked in a study of one country alone. This study focuses on hospitals in London and Philadelphia, which were both major centres for development in nursing and medicine during the study time period. The time period for this thesis is 1860 to 1914. It begins with the opening of the Nightingale School at St. Thomas’s Hospital in London in 1860 which served as a model for other hospital training schools for nurses in London and Philadelphia. The bulk of the material for the study comes from the 1880s to the early years of the twentieth century as multiple formal hospital nurse training schools developed in important hospitals in both cities. Various factors were identified which contributed to the context in which nursing developed in London and Philadelphia during the study time period. This study examines conceptualisations of nursing and nursing work in relation to medicine and doctors’ work particularly through Nightingale’s writings and the elaboration of her ideas by her friend Eva Luckes, matron of the London Hospital as well as material in nursing textbooks. The study also looks at relationships between nurses and medical staff as they worked on hospital wards, particularly the effect of the presence of many medical students on the wards of London hospitals and their absence in Philadelphia. The importance of strong nurse leaders within hospitals in regard to separation of hospital nursing and medical services is examined. Harmony and discord between nurses and doctors is examined in order to understand factors which contributed to tensions between doctors and nurses. The case of the development of physiotherapy reveals important aspects of relationships between nursing and medicine in society.

Background: Saudi Arabia has always been dependent on non-Saudi nurses. However, the recruitment of these nurses has been challenged by the consequences of the first Gulf War of 1991 and the political unrest in the Middle East ever since. Moreover, the annual supply of Saudi nursing graduates has been insufficient in meeting the demands of the expanding healthcare services. Indeed, Saudi nurses make less than 30% of the total nursing workforce Kingdom wide. The Saudi literature links the shortage in Saudi nurses to socio-cultural factors found to influence the prevailing negative images and perceived low status of nursing. Hence, I have developed a personal interest to explore the impact of prevalent images and perceived status of nursing on the Saudi nurses’ perceptions of nursing as an occupational choice. The reviewed literature guided the development of a framework for my study using six concepts. Aim: To gain an understanding of the social, cultural, economic and political influences on Saudi nurses’ perceptions of nursing and their impact on recruitment of nursing students and retention of graduates. Method: Sixty eight semi-structured interviews were conducted in Jeddah, Saudi Arabia with a sample of student nurses (n = 38), staff nurses (n = 21) and senior nurses (n = 9) from government and private sectors. A purposive sampling approach increased the likelihood that the variability within nursing was represented in the data. A focus on the inclusion of Saudi male nurses is unusual; it allowed this study to explore gender issues in more depth. The interview guides covered selected concepts derived from the literature. These include: nursing images; status of nursing; perceptions of nursing as an occupational choice; nursing education; gendered-nature of nursing and nursing support systems. Interviews were conducted and transcribed in Arabic and participants were interviewed once. A socio-demographic checklist was filled at the end of each interview. Findings: Findings were presented using three explanatory themes. First, perceptions of nursing suggesting that, against a background of negative gender-related perceptions of nursing, there is an increasing recognition of nursing as a secure occupational choice in a shifting labour market. Second, challenges facing professionalism suggesting that participants acknowledged the importance of achieving a recognised professional status for nursing. Third, dealing with personal struggle suggesting that participants have been experiencing a personal struggle as they were learning to cope with the prevalent negative perceptions of nursing at social and professional levels. Conclusions: Findings from the study provide evidence of a personal struggle female and male participants have been experiencing in their attempts to transcend through shifting gender, social, cultural, economic and global boundaries. A struggle they had to deal with in order to achieve social and professional recognition. Overlooking causes of struggle might risk Saudi nurses’ recruitment into and retention within nursing. A new model for the Saudisation of nursing workforce has been proposed. Policy makers are requested to divert their strategies from focusing only on graduates from the nursing programmes to targeting Saudi school children. They are expected to design and implement Saudisation strategies that aim at changing the prevailing gender-related perceptions of nursing as an occupation among prospect candidates; and building on the nurses’ efforts to achieve professional recognition and integrate success in their career with their personal life.

Aim: To examine the adoption of CCDS by paramedics, including the impact of CCDS on paramedic role and practice. Methods: Systematic review of CCDS in emergency care followed by a cluster-randomised controlled trial (C-RCT) of CCDS with a qualitative component involving 42 paramedics at two study sites. Results: 19/20 studies identified for inclusion in the systematic review were from the Emergency Department setting, with no studies from prehospital care. The focus of the studies was on process of care (19/20) rather than patient outcomes (5/20). Positive impacts were reported in 15/19 (79%) process of care studies. Only two patient outcome studies were able to report findings (one positive, one negative). Results relating to CCDS implementation were reported as an ad hoc response to problems encountered. In this C-RCT paramedics used CCDS with 12% of eligible patients (site one: 2%; site two: 24%). Intervention paramedics were twice as likely to refer patients to a falls service as those in the control group (usual care) (relative risk = 2.0; 95% Cl 1.1 to 3.7) although conveyance rates were unaltered (relative risk = 1.1; 95% Cl 0.8 to 1.5) and episode of care was unchanged (-5.7 minutes; 95% Cl -38.5 to 27.2). When CCDS was used patient referral to falls services was three times as likely (relative risk = 3.1; 95% Cl 1.4 to 6.9), and non-conveyance was twice as likely (risk = 2.1; 95% Cl 1.1 to 3.9) and overall episode of care fell by 114 minutes (95% Cl from 77.2 to 150.3). Reasons given for not using CCDS included technical problems, lack of integration, it was not sophisticated enough to influence decision making. Paramedics adapted when and how they used CCDS to suit context and patient condition. Conclusion: There is little existing evidence in relation to CCDS use in the emergency care setting, and the prehospital emergency care setting in particular. Studies of CCDS undertaken in emergency departments have shown benefit, particularly in relation to process of care. The C-RCT found that CCDS use by paramedics was low, particularly at site one, but use was associated with higher rates of patient referral and non-conveyance, and shorter episodes of care. There were encouraging signs that CCDS can support a new decision making role for paramedics. The study provides useful lessons for policy makers, practitioners and researchers about the potential benefits of CCDS and the challenges to adoption of new technology in emergency prehospital care.

In the study reported in this thesis a conceptual framework drawing on a range of social, organisational and educational theories was used to underpin an investigation into the social organisation of practice nurses’ knowledge utilisation. Particular attention was paid to the concept of ‘clinical mindlines’. Changes in healthcare delivery, particularly in primary care, have resulted in changes to practice nurses’ roles. Macro level policy has focused increasingly on standardisation of care within the primary care environment, specifically in relation to management of chronic/long term conditions. Practice nurses have additionally taken on roles that include diagnostic and treatment elements for which they were not prepared for in their initial training. Set against this background ethnographic data were generated relating to meso level organisation of knowledge utilisation in two study sites. Interviews, observation and documentary analysis of available knowledge sources including guidelines and protocols were used to generate data relating to how knowledge is accessed and subsequently used at the micro level of the clinical patient encounter. Findings illustrated that a mixture of organisational and individual factors impacted on knowledge utilisation. Practice nurses used a combination of knowledge which they applied within the context of the individual patient encounter. This was accessed partly through their ‘mindlines’ developed from education, clinical experience and social learning and partly through accessing a ‘bricolage’ of knowledge which included seeking advice from a variety of sources. Specific elements of note were enthusiasm towards evidence based practice, both amongst the nurses and at practice level and a supportive organisational culture towards continuing education and sharing of knowledge. Standardisation embedded into computer templates that guided the chronic disease management consultations had both a positive and negative influence, positive in its focus on improving evidence based care, whilst negative in promoting template driven care that takes little account of individual patient need. Organisational elements constraining effective knowledge dissemination and use included information being disseminated to the practice nurses through vertical rather than horizontal networking; professional training that had not prepared nurses to deal with uncertainty; the part time nature of the practice nurse role; limitations in accessing evidence in ‘real time’ and lack of applicability of evidence to all patient scenarios.

The central objective of the study was to better understand 5th and 6th year school pupils’ perceptions of nursing as a career choice and to obtain current data regarding the recruitment situation pertaining to school leavers pursuing nursing as a career choice. This was achieved by utilising a multi-strategy approach which involved the use of a self-administered questionnaire (n = 1062) and the interviews of 20 paradigmatic cases. The school pupils came from 11 schools, with different socio-demographic profiles, from one educational area in Scotland. The study found that only 8.8% (n = 56) of school pupils who had made a career choice had chosen to pursue nursing as a career, despite the fact that 82.4% of the school pupils in the sample had the necessary academic qualifications to enter the student nurse education programme. Merely 21.2% of all the pupils had actually considered nursing as a career choice. The findings would appear to suggest that those pupils who had chosen to pursue nursing as a career choice are committed to this choice. As 93% of the pupils would still continue to pursue nursing as a career choice even if they obtained better grades in their examinations than they expected. Equally resolute in their choice were the pupils who had chosen not to pursue nursing. Of the school pupils in the sample who had not chosen to pursue nursing as a career choice 88.5% of the school pupils stated that even though they did not get the exam grades that they expected they still would not pursue nursing as a career. What was also significant was that of the school pupils who had not chosen nursing as a career choice 86.9% of the pupils stated that they would not consider nursing as a career option in the future. The gender breakdown of school pupils who had made a career choice showed that 2.5% of male pupils who had made a career choice had chosen to pursue nursing. 14% of female school pupils who had made a career choice had chosen to pursue nursing. Further examination in relation to the gender breakdown of those pupils who had chosen to follow nursing as a career revealed that males only accounted for 12.5% whereas females accounted for 87.5%. This would seem to propose that a gender bias still exists in relation to nursing as a career choice. Nursing was not ranked particularly highly by the pupils as a career choice. Male pupils ranked nursing 13th out of the 14 main career choice categories. While female pupils ranked nursing 8th out of the 14 main career choice categories, this being only slightly better than secretarial/administration. Parents appeared to have a major influence on the pupils’ career choice and there was evidence that parents as well as further significant others were influencing against a career in nursing. Nursing does not seem to be a popular career choice among school pupils. There is strong evidence from the questionnaire data to suggest that there are a number of problem indicators which could propose that recruitment of school pupils into nursing could prove extremely difficult even with the proposed increase in the number of school leavers entering higher education. This could have a serious impact on nursing care delivery within the United Kingdom as the nursing population continues to age. The paradigmatic cases interviewed were 20 high academic achieving school pupils who at one stage in their career choice process had considered nursing as a career choice. Despite considering nursing as a possible career choice none of the 20 pupils went on to pursue nursing as a career. The qualitative interview findings appeared to suggest that nursing was not a credible career choice consideration for high achieving pupils. There was a very strong feeling amongst the pupils that nursing would be a waste of their academic qualifications with a belief that nursing was not a career choice for intelligent pupils with good examination grades. Also that they could help people at a much higher level than nursing by becoming a doctor with a prevailing belief that knowledge and caring are polarised – doctors cure and nurses only care for patients. The status of nursing as a career choice was not high amongst the pupils and this was influenced by the type of person that they had observed who were nurses mostly, in their opinion, women who were weak and had no power within society. Also the perceived nature of the job that nurses do with the prominent belief that what nurses do is principally practical in nature having no intellectual aspects, for example making beds, washing and feeding patients. The influence of significant others, these being specifically parents, guardians, guidance teachers and careers advisors was very apparent in the data in that they had a very negative view regarding nursing as a career choice for high academic achieving school pupils. Participants reported that their parents were actively and vigorously discouraging them away from a career in nursing because of the pupils’ good examination grades and the belief that the pupils could do something better than nursing. Also the participants reported that their guidance teachers and careers advisors were assertively steering them away from nursing as a career choice because of their perception that nursing was a low status career choice requiring little intellectual ability and was on a par with hairdressing, office work and being a secretary. In addition the school pupils stated that guidance teachers and careers advisors were more interested in and attempted to have a greater influence on the career choice of the high academic achieving school pupils opposed to other less academic pupils. Only two of the pupils stated that they believed that their career choice was their own decision. With the majority of school pupils valuing the opinion of their parents regarding career choice and with parents along with associated significant others being a major influence on the school pupils’ career choice and advising against a career in nursing. There was strong evidence from the interview data to suggest that the chances of recruiting high academic achieving school pupils into nursing would appear to be negligible. There was also evidence that the image of nursing as an occupation was an important determining factor in the school pupils’ career choice. The pupils displayed a negative image of nursing and this was influenced by a number of factors. The negative image of nursing depicted in television programmes; the negative image of nursing portrayed by people who are nurses; the sexual stereotype image of female and male nurses; and the image that it is very easy to get into train to be a nurse. What was also concerning was that the pupils had few positive and contemporary images of nursing. Also with regard to the image of nursing the data showed that the pupils considered it important to join a profession. Nursing was deemed not to be a profession and did not merit being a profession because it was believed that the entry to student nurse education programmes is not strictly controlled therefore it is easy to get into nursing. There was a strong consensus among the high achieving school pupils regarding their image of the archetypical school pupil who would select nursing as a career choice – their view was of a predominantly unexceptional individual who was mostly female, no more than average intelligence, kind, caring, good listener, good practically and can follow task orders. This view of the typical school pupil who would enter nursing as a career, that of a person with a low academic achievement record, conflicts with their own personal typology and thus became a further important dissuading factor regarding nursing as a career choice for them.