The aim of this thesis is to develop a grounded understanding of the practice of high technology clinical work and how it is organised. It combines systematic empirical analysis of the clinical locale of intensive care with scholarly work in medical sociology and the related fields of health services research, medicine, nursing and social studies of science and technology. The empirical data were obtained through fieldwork on three intensive care units (ICUs). The methods comprised periods of detailed observation, informal conversational interviews in the field and tape-recorded semi-structured interviews. The substantive contribution of the thesis is an analysis of contemporary and traditional themes in medical sociology: medical uncertainty; clinical knowledge in practice; inter- occupational relationships; the material and social character of medical and nursing work; and the organisational 'reality' of one clinical site within the modem hospital. In particular, the thesis demonstrates the utility of 'craft' as a metaphor for understanding medical work in ICU; provides a critical empirical review and reformulation of nursing theory as it has been applied to ICU; and proposes a new conception of the relationship between medicine and nursing in the grounded situation of clinical work. Two subsidiary contributions are also made: one methodological and one theoretical. In terms of methodology, I provide concrete examples of how ethnographic analysis can explain findings which have been derived from other health services research methods and thereby inform the future direction of such research. In terms of theory, I illuminate current debates at the interface of medical sociology and social studies of science and technology about the appropriateness of a post-structural style of analysis. In conclusion, I specify in what ways our understanding of health care work is - and is not - enhanced by the adoption of Actor-Network Theory.

Despite significant developments, critical care mortality remains high at - 20-30%. Muscle wasting with protein breakdown is frequently seen in critically ill patients with increased amino acids release from muscle tissue, of which alanine and glutamine compose a large proportion. Plasma glutamine is rapidly utilized and circulating plasma glutamine declines rapidly. Low plasma glutamine concentrations correlate with mortality in critical illness and intravenous glutamine supplementation improves survival of the critically ill patient. The precise mechanism whereby this protection is afforded remains uncertain, although evidence suggests that glutamine plays an important role in the ability of cells to respond to stress. The expression of stress or heat shock proteins (HSPs) is one of the most highly conserved mechanisms of cellular protection. Increased intracellular HSP content is associated with a striking preservation of muscle mass and function and low muscle and serum HSP 70 content in severe trauma correlate with increased mortality. Glutamine infusions facilitate increased HSP expression. Further, glutamine infusions enhance HSP content in multiple organs of the rat with a significant protection of these organs from damage during sepsis and a mortality advantage. This has resulted in the hypothesis that glutamine deficiency leads to a modified HSP content of muscle cells and a diminished ability to mount a stress response. Administration of glutamine will have a direct and beneficial effect on the HSP content of muscle in cell culture and during critical illness.

Rapid Response Systems but is dependent upon nurses utilising EWS protocols and applying Acute Life-threatening Events: Recognition and Treatment (ALERT) course best practice guidelines. To date there is limited evidence on the effectiveness of EWS or ALERT as research has primarily focused on measuring patient outcomes (cardiac arrests, lCU admissions) following the implementation of a Rapid Response Team. The aim of this study was to evaluate factors that enabled and constrained the implementation and service delivery of Early Warnings Systems (EWS) and acute care training in practice in order to provide direction for enabling their success and sustainability. The research design was an embedded multiple case study approach of four wards in two hospitals in Northern Ireland. It followed the principles of realist evaluation research which allowed empirical data to be gathered to test and refine RRS programme theory. This approach used a variety of mixed methods to test the programme theories including individual and focus group interviews, observation and documentary analysis of EWS compliance data and ALERT training records . Data synthesis found similar regularities or factors enabling or constraining successful implementation across the case study sites. Findings showed that personal (confidence; clinical judgement; professional accountability; personality). social (ward leadership; communication), organisational (workload; time pressures; staffing levels and skill-mix), educational (constraints on training and experiential learning) and cultural (delegation of observations. referral hierarchy; rigid recording practices) influences impact on EWS and acute care training outcomes. RRS theory refinement using realist evaluation explained what works, for whom in what circumstances. Future service provision needs to consider improved staffing levels; flexible implementation of protocols underpinned by empowerment and clinical judgement; on-going experiential ward-based learning and enhanced clinical leadership to enable the success and sustainability of Rapid Response Systems.

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This thesis presents a body of publications, in the area of critical care nursing, for consideration for the award of Doctor of Philosophy by Publication. The thesis is presented in three chapters: Introduction; Body of Work; and Research, Knowledge, Evidence and Practice. In the first chapter the emergence of evidence-based practice is described, in general. Initially, an overview of the origins and trends of nursing research methodology is provided; the purpose of which is to set in context the body of work. Utilising a narrative approach (Boje, 2001; McCance et aL, 2001; Sandelowski, 199 1; Vezeau, 1994) as a 'personal journal of discovery' I then reflexively describe my own development as a nurse researcher practitioner, drawing on my own publications to illustrate my progress, the development of my thinking, my research practice and the development of my understanding of pragmatice pistemology. The second chapter is comprised of my publications relevant to critical care nursing. Spanning a period of eleven years, they represent my contribution to critical care nursing knowledge. In the concluding chapter I have summarised initially my own contribution to critical care nursing knowledge, before moving on to a more detailed critique of evidence-based practice. Finally I have made recommendations for the way forward. In addition to presenting my body of work, the aim of this PhD is to challenget he current concept of evidence-based practice, arguing that its definition is too narrow to encompass the rage of different types of knowledge that nurses use when caring for critically ill patients. I have utilised my own publications, to demonstrate how a variety of approaches are necessary to provide the best evidence for developing practice. I have positioned my argument within a theoretical understanding of pragmatic epistemology. In this way, I am working towards the development of a science of practice. Simultaneously I am also, to some extent, challenging conventional concepts of what constitutes doctoral level knowledge and how a PhD looks. My conclusion is that critical care nursing knowledge is drawn from many sources, and should be applied in an integrated way that enables practitioners to make a positive difference to the life of patients.Knowledge that is not or cannot be applied to practice is therefore of no value. The valuing of practice knowledge brings with it the requirement that all forms of knowledge (and their relevant methodologies) are considered as equal,in terms of their potential to impact on practice and that nothing should be rejected on paradigmatic grounds. In contemporary healthcare evidence is hierarchically valued and this raises many questions of equity. Where the value of knowledge becomes unequal is when its application to practice is limited. The corollary of a pragmatice pistemology is that it requires a pragmatic process to make it work. For me, at this point in time, the best available is practice development. In summary,this thesis represents a construction of work that makes an original contribution to knowledge. The product of my thesis is a theory of pragmatic epistemology as the basis for a science of practice.

Previous research has suggested that critical care nurses' close and prolonged contact with patients places them in a unique position of improving patient outcomes and reducing the demand on critical care beds by detecting subtle signs of deterioration in a timely manner and identifying patient progression and readiness for less intensive care. Nonetheless, nurses rarely take decisions about patients' treatment modalities on their own, and constantly need to seek advice or authorisation. Indeed, several studies suggested that one of the most frequent decisions taken by nurses during clinical practice is that of referring to medical, nursing or other health care practitioners. However, there is very Iim ited research around the factors related to, and the actual process of, such referring. In view of this gap in the literature, the purpose of this study was to explore and explain the process of referring in the context of an intensive care unit by means of a substantive theory derived from the data. The principal research question was: What are the factors associated with critical care nurses' decisions to seek help from medical practitioners? The study took place in a general intensive care unit in a state hospital in a Mediterranean island nation. Data generation and analysis took place concurrently and iteratively, and were guided by the dimensional analysis approach to grounded theory. Data collection involved : (1) twenty hours of preliminary non participant observation; (2) fifty hours of participant observation and informal interviewing; (3) fifteen hours of formal semi-structured interviews with ten critical care nurses working in this unit selected by means of purposive and theoretical sampling; (4) two 2-hour focus group sessions aimed at enhancing theoretical sufficiency and verification of the emerging substantive theory. The analytical process was characterised by a series of inductive-deductive cycles, during which increasingly conceptual labels were attached to data segments. Working hypotheses and theoretical memos were used to interrogate the data and look for positive and negative evidence for the inductively derived labels. The findings suggest that nurses' decisions to seek help from doctors are complex and frequently mediated by individual or organisational factors which are unrelated to the actual clinical situation, such as experience, asse11iveness and willingness to take risk. They involve nurses weighing up several occasionally conflicting motivators, including a desire to act with some degree of independence; attempting to prevent personal and professional risk; and being constantly mindful of their asymmetrical decision making power relative to doctors. A central consideration is that of balancing their moral obligation to safeguard critically ill patients' interests with their duty to respect medical practitioners' preferences. Subsequently, nurses find themselves in a position of dual agency as they need to concurrently act as an agent to two different principals, namely the medical practitioner and the patient, a situation which is potentially morally distressing. The emergent substantive theory underscores the significance of the nurse's role in acting on behalf of the patient in a scenario of significant patient vulnerability; the factors that enhance, mediate and potentially suppress this advocacy role; and the interrelatedness of nurses' relationship with doctors and their effectiveness in safeguarding critically ill patients' interests. Subsequently, the study should provide valuable insight into the type of leadership and education that is required to assist nurses in placing patients' interest at the forefront of their actions and interactions, while fostering collaboration within multidisciplinary teams.

The intention of this case study research is to explore the factors that facilitate or inhibit effective leadership in Critical Care Settings (CCSs) in a government hospital in Bahrain. The study focuses on Head Nurses (HNs) working in the CCSs, since those positions play a pivotal role in creating and maintaining a Healthy Working Environment (HWE) for nursing practice. In this research the abbreviation ‘Head Nurse (HN)’ will be used and it stands for Charge Nurse/ Ward Sister/ Nurse Supervisor. According to Ministry of Health (MoH) policies, the leadership in Bahrain encounters a variety of challenges including: demands for efficiency, cost cutting and a value for money service; finding alternative ways of funding; ensuring appropriate human resources; supporting improved management practices; developing a proper structure; higher customer expectations; and knowledge armed customers. A qualitative case study design was used. This approach allows the study to explore the important factors that facilitate or hinder leadership effectiveness such as the individual professional factors (e.g. leadership style, communication, the relationship, and the educational factors) and the organizational factors which include for example healthy working environment and the organizational structure. Data were gathered through in-depth semi-structured interviews with key informants (KIs), HNs and Senior Staff Nurses (SSN), as well as through observing HNs in clinical practice and document analysis (e.g. minutes of meetings and department annual reports). The emerging qualitative data have been analysed through coding and grouping according to themes. The findings revealed that effective HN leaders were recruited, and designated to the posts without development plans or without formal presentation. There was a lack of effective HN leaders who have the capabilities that are considered crucial in such a role (e.g. characteristics of emotional intelligence and authenticity). The study findings generated generic issues surrounding leadership in healthcare settings which resonate with the literature. The participants in this study talked about the characteristics of effective leaders in general rather than specifically emphasizing on issues like being in the frontline during a crisis to make quick decision that are required in critical situations. Key messages from the research indicate that effective head nurse leaders play a pivotal role in establishing and sustaining a healthy working environment. Also head nurses working in critical care settings should exhibit specific characteristics such as being: empathetic, open and honest, optimistic, visionary, accessible to be effective leaders.

Nursing scholarship and healthcare policy set an expectation that nurses should think about patients as persons. Nevertheless, the literature reveals that critical care nurses can struggle to perceive patients as persons, and thus suggests they may think about patients in different ways. This thesis presents the findings of an ethnographic study undertaken within one critical care unit in the United Kingdom which examined how critical care nurses do think about patients. A purposive sampling strategy recruited 7 participants representing both experienced and inexperienced critical care nurses. Data were collected over a period of 8 months during 2006 to 2007, and primarily comprised the field notes from 92 hours of participant observation supplemented by 13 tape recorded interviews. Data analysis was influenced by Foucault and Goffman and adopted the perspective of linguistic ethnography. Analysis revealed that all participants thought about patients in seven distinct ways: as ‘social beings’, as ‘valued individuals’, as ‘routine work’, as a ‘set of needs’, as a ‘body’, as ‘(un)stable’ or as a ‘medical case’. Accounts of participants’ practice revealed that they had a tacit understanding that these different ways of thinking related to aspects of one coherent whole, but no one way of thinking could be characterised as thinking about this ‘whole person’. Nurses could only think about one aspect of the patient at a time. Nurses’ practice was not guided or explained by their thinking about patients as persons, but rather expert practice was characterised by nurses’ fluid and appropriate movement between different ways of thinking about patients. When participants talked about their practice it was evident that these nurses could only legitimately talk about themselves as giving care to persons. Participants characterised some of the ways in which they had to think about patients as impersonal, and this actively hindered these nurses from describing or reflecting upon elements of their practice. There is therefore conflict and dissonance between nurses’ expectation that they should think about patients as persons, and the fact that delivering nursing care requires them to think about patients in different ways. The development of future critical care nurses will require practitioners and educators to recognise that nurses think about patients in different ways, and that expert practice is characterised by the clinical wisdom which enables nurses to think about patients in ways which are appropriate to the moment. Nurse scholars and educationalists should therefore avoid claims to a unique professional knowledge base which suggest to nurses that some ways of thinking are always inappropriate or inherently reductionist. Instead, there is a need for scholars and policy makers to articulate a vision of person centred care clearly, and in ways which avoid constructing dissonance between nurses’ ideals, and the ways in which they do and must think about patients.

patients and their families. The purpose of the study was firstly, to explore and interpret the meaning of the experiences of critical care nursing students about clinical accompaniment in open distance learning (ODL). This aspect has not been researched before and as such, there is no empirical data about the clinical accompaniment of the critical care-nursing students in ODL. Secondly, to develop guidelines for facilitation of clinical accompaniment in critical care nursing in ODL. A qualitative hermeneutic phenomenological study was conducted. Non-probability purposive sampling was used to select participants to provide information about clinical accompaniment in ODL. Data was obtained through in-depth interviews supplemented by field notes compiled during fieldwork. The study findings revealed that participants regard relationships and communication as important for clinical accompaniment. The distance factor inherent in distance learning was problematic for student’s motivation and support. The presence and visibility of the lecturer was pivotal for the students. Of importance also were the relationships with the managers and colleagues. The perception of participants was that managers of clinical facilities were not as readily accessible as would have been the lecturer. Although negative experiences were described, paradoxically these experiences seemed to have empowered the student to develop survival skills, patience and assertiveness to take action on how to deal with the situation. From the findings the researcher was able to develop guidelines the implementation of which, is hoped to ensure effective clinical accompaniment of critical care nursing students in ODL. / Health Studies / D. Litt. et Phil. (Health Studies)