This study was a qualitative examination of patient and staff experiences within a redeveloping acute NHS hospital Trust in England. The aim of the investigation was to examine the current direction in government policy which places considerable emphasis upon delivering healthcare services structured broadly around increased patient involvement and choice. There is a need to address the gaps in the evidence for this strategic direction, which indicate an apparent lack of appreciation for the complexities involved. The qualitative methods applied in the study included the use of patient and staff interviews, observations and some documentary review. The research location was selected as an opportunity to assess and compare the perceptions and experiences of patients and staff in the context of a hospital redevelopment programme, from within three distinct clinical services. The three clinical services studied were accident and emergency, a paediatric ambulatory care unit and an adult respiratory outpatient clinic. Thematic content analysis was applied to the data. Findings indicated that generally patients were satisfied with their care and did not expect greater control or involvement. Some issues were raised by staff around uncertainty towards the change programme. Furthermore, there was a suggestion that staff and patients had differing perceptions of what constituted satisfactory care, with respect to technical versus functional quality. The notion of a ‘model’ of patient behaviour emerged. The conclusion is that given the current political agenda focused on the role of the patient, greater sensitivity in understanding towards terms such as patient-centred care, involvement and choice is required. Additionally, there is a need for greater awareness and appreciation of the discrepancy between staff and patient perspectives of what impacts the patient experience. Further research might focus upon the understanding of the patient processes and interactions involved with respect to patient-centred care and choice.

Recent genome-wide studies have identified novel loci associated with cardiovascular diseases, but the mechanisms mediating these associations are unknown. Investigation of intermediate phenotypes can identify the pathways involved and potential targets for therapeutic intervention. This study investigated the relationship with intermediate phenotypes at risk loci on chromosome 9p21 and 2q24. Chromosome 9p21 polymorphisms are associated with coronary artery disease and congenital intracranial aneurysms. In the present study risk variants were not associated with traditional risk factors, inflammatory mediators, carotid artery intimamedia thickness, echocardiographic measures of cardiac structure and function, or congenital heart defects. There was no evidence of copy number variation using MLPA. To identify genes involved in mediating disease susceptibility this study examined the association of chromosome 9p21 variants with peripheral blood expression in healthy subjects of three neighbouring genes: two cyclin-dependent kinase inhibitors, CDKN2A and CDKN2B, and a non-coding RNA of unknown function, ANRIL. Novel methodology combining allelic expression data from multiple transcribed markers was more powerful than total expression analysis for mapping cis-acting effects. Multiple loci were independently associated with expression of each gene, suggesting that several sites may modulate disease susceptibility. Disease-associated variants were all associated with allelic expression of ANRIL, while association with the other two genes was only detectable for some risk variants. Variants had an inverse effect on ANRIL and CDKN2B expression, supporting a role of antisense transcription in CDKN2B regulation. This study suggests that modulation of ANRIL expression mediates susceptibility to several important human diseases. Chromosome 2q24 polymorphisms were associated with hypertension in a study involving an Amish population; in vitro experiments suggested that influences on STK39 expression might mediate these effects. In the present study allelic expression analysis confirmed that reported SNPs were associated with STK39 expression in vivo, but were not associated with blood pressure in a large British cohort.

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The study reported within this thesis sought to better understand nursing home placement from multiple perspectives. Using a two stage approach, data were collected from semi-structured interviews with 37 people who had assisted a close relative to move into a nursing home, together with case studies in three nursing homes which explored how relatives are supported in maintaining their caring role in this new context. Data analysis revealed three phases to the transition: 'making the best of it'; 'making the move' and 'making it better', with relatives' experiences across these phases being understood in terms of five continua, reflecting the extent to which they felt they were: operating 'under pressure' or not; 'in the know' or 'working in the dark; 'working together' or 'working alone'; 'in control of events' or not, and 'supported' or 'unsupported' both practically and emotionally. Data from the case studies demonstrated the utility of these factors in understanding the experiences of relatives, residents and staff working in the care homes. In particular, the extent to which carers were able to meet their ultimate goal, that of ensuring 'best care' for their relative was influenced by these factors and the type of 'community' operating in the home. Analysis identified three types of community within the care homes studied: the controlled community; the cosmetic community; and the complete community. Findings suggest that the 'complete community' is consistent with the most positive experiences for older people, for family caregivers and for staff, and therefore promotes 'best care'. The ways in which staff, carers and older people can help to forge a complete community are considered.

Statutory supervision is a system established in 1902 to inspect and regulate midwives practise, in order to protect women. It has developed subsequently to support midwives' practice whilst simultaneously protecting women. Drawing on a range ofliterature sources and topics, the study critically analyses the context in which midwife lecturers practise and evaluates how they make sense of statutory supervision. The theoretical framework for this qualitative study is based on social constructionism and relational autonomy. In order to analyse midwife lecturers' view of their role and experiences ofstatutory supervision in a University setting, the study is divided in two stages. The first stage is a questionnaire surveying the experiences of254 midwife teachers and 11 Local Supervising Authority Midwifery Officers (LSAMO) in England. The second stage involved semi-structured interviews with ten volunteers recruited from the survey. Results were analysed using voice centred relational analysis and framing analysis. Based on the analyses ofthe respondent's experiences, several themes emerged. Individuals define the meaning ofsupport differently which sometimes conflicts with the support available from statutory supervision: statutory supervision predefines who offers the support and cannot guarantee psychological safety. Support skills are essential for all midwives and essential in relationships with colleagues, students and users. Decisions regarding the fitness to practise of a midwife or student midwife should involve and welcome the participation and contribution of users ofthe service to promote greater accountability and openness. A national study should examine new ways ofworking for midwives based in higher education to create meaningful and manageable ways of blending an academic and midwifery identity.

Methods: Study one; cross sectional survey of all acute mental health nurses working at 10 MHS Trusts (n=2130). The survey contained a validated attitude scale (ATAMH) and questions exploring a range of personal, professional and organisational variables. Study two; semi-structured interviews with acute mental health nurses and service users with experience of acute inpatient care. Results: Study One: The mean total attitude score was 172 which is positive, the maximum score available is 255. Multiple regression analysis identified seven predictors of attitudes which accounted for 21.3% of the variance in the total attitude score: pay banding; influence of psychosocial approaches; influence of involving service users; experience of working in the community; education at post graduate/higher degree level; being up to date on policy, research and practice relevant to acute mental health care; having personal and family experience of mental health problems. Study Two: 16 nursing staff from two units covering a range of pay bands and length of experience were interviewed. Ten service users with a range of acute inpatient experience were interviewed. Three overarching themes were identified: 1) Pre-determined factors influencing attitudes such as personality, reasons for doing the job, personal and family experiences of mental health problems 2) Wider contextual factors such as clinical leadership, patient stereotypes, ward culture and team values 3) Outcomes of nursing practice and the service users experience of care. Nurses who had positive attitudes made patients feel valued. Nurses with negative attitudes made patients feel like they were a pain and not deserving of care. Service users believed pre-determined factors had the greatest impact on nurses' attitudes. Nursing staff placed greater emphasis on the influence of contextual factors and underestimated the impact of attitudes on service users' experience.

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The aim of the study was to investigate how nurses detected and reported physiological deterioration in acutely ill patients. To date there is a paucity of research on how nurses pick up deterioration. The emphasis within the literature tends to be on identifying premonitory signs that may be useful in predicting patients who are in danger of deterioration. Changes in respiratory rate is the most consistent in picking up such patients (Fieselmann et al. 1993; Sax and Charlson 1987; Schein et al. 1990; Smith and Wood 1998) but in common with other signs, it lacks sensitivity and specificity. The sample consisted of 44 nurses, doctors and health care support workers working on a general medical and surgical ward. Data were collected by means of non-participant observations and interviews, using grounded theory as originated by (Glaser and Strauss 1967) and (Glaser 1978). As data were collected, the consistent comparative method and theoretical sensitivity were used as outlined in grounded theory. A theory of "making credible" emerged, together with its sub-core categories of "intuitive knowing", "contextualising" and "grabbing attention". The problem that nurses face in referring patients they suspect are deteriorating is in persuading doctors to come and review them. How nurses deal with this is a three stage process. Through intuitive knowing they pick up that patients have changed in a way that requires a medical assessment. To make the referral more credible, nurses attempt to contextualise changes by establishing baselines of how patients are in terms of their progression and vital signs and continual vigilance. Finally with the backup of colleagues, nurses refer patients by providing as much persuasive information as possible. The whole process is facilitated by knowledge and experience, together with mutual trust and respect. Cautiousness characterises each step.