This case study explored the factors that influence the experience of night-time postural management equipment by children with cerebral palsy in the South-West of England. The aims were to explore the views of children on using a sleep system, the role of their parents and therapist in its use and the quality of sleep experienced before and during use of a sleep system. Further objectives were the identification of factors that affect the use of sleep systems and the production of findings to guide therapists' clinical practice. Seven subunits made up the whole case, with each one consisting of a child, aged 18 months to nine years who had just been prescribed a sleep system, the child's therapist and parents. All participants, excepting children under three years old, were interviewed. Talking Mats, an innovative communication tool, was used to enable children with little or no verbal communication to give their views. Children as young as three years old were able to express their views on sleeping in a sleep system and to provide reasons for waking in the night. The findings included sleep difficulties in six out of seven children, two of whom improved with the use of a sleep system. Six children were thought to experience regular pain or discomfort, two of whom were more comfortable when sleeping in their sleep system. Factors were identified that influenced whether a child and family were able to continue using a sleep system at night including the finding that some of the therapists who were prescribing sleep systems did not have the necessary knowledge and experience. It was concluded that when children are given the appropriate tools they can have a voice and be able to practice making decisions about their healthcare. It is suggested that when considering prescription of a sleep system, use of the ICF framework model would assist clinicians in focussing on those factors that predict the child and family are most likely to continue to use it. Therapy services should consider the role of a specialist clinician to lead local postural management services and to put in place training and competency measures for generalist therapists to ensure that they have the necessary knowledge and experience.

For midwifery practitioners, the concept of excellence is central to the ethos of quality midwifery care (DH 2009, NMC 2009) and although midwives are being asked to aspire to ‘a standard of excellence’ (DH 2009), the meaning of ‘excellence’ for both women and midwifery practitioners has not been defined. The focus of this study is to understand excellence at a personal level, what makes some midwives ‘stand out’ and what it means to ‘be’ an excellent midwife, from the service users perspective.

This work grew out of a need to try to understand my often experienced sense of being misunderstood, misrepresented and marginalised. A prerequisite to helping others in mental health nursing is arguably some requirement to understand one’s self. But who is the self? In this thesis I use an autoethnographic approach to examine how the self, multiple selves and identity formation is socially constructed. Social constructionism contends that categories of knowledge and reality are actively created by social relationships and interactions. As an autobiographical genre of writing, this evocative autoethnography has been written in the first person displaying my multiple layers, connecting my selves to the cultures I inhabit. As a reflexive methodology it offers the researcher a means of critically exploring the social forces and discursive practices that have shaped his own cultures. In addition I discuss the contrast between traditional guidelines and protocol driven ethics with more progressive relational ethics. Central to relational ethics is the question ‘What should I do now?’ rather than the statement ‘This is what you should do now.’ I continue by arguing that we use stories as ‘equipment for living’, as tools to understand, negotiate and make sense of the many different situations we encounter. In recent years, as part of the ‘narrative turn’ in the social sciences, a growing number of scholars have suggested that we live in a world shaped by these stories. I discuss connections between the cultures people occupy and how an individual’s reflexivity can keep them stuck or liberated and emancipated with regard to their personal narratives. Whilst the text is not intentionally instructional, storytelling can be instructive. By showing my vulnerabilities the work is a prism for the reader to reflect on their narratives and the cultures they inhabit.

Breech birth has become a rare phenomenon in England over the last two decades. 3-4% of all babies present bottom or feet first at full term (37-42 weeks gestation) and despite conflicting research about the safest mode of delivery for breech presentation, the vast majority of breech babies will be delivered by planned caesarean section. The small number of qualitative research studies suggest that the experience of breech has complex meanings for childbearing women. This research intended to explore these elements further and to better understand this experience within a social, cultural and gendered context.

This study explores the introduction of an approach called Pre-Therapy to staff working with people with dementia. Pre-Therapy contributes to the existing range of therapeutic approaches which aim to engage with the subjective experience of the world of people with dementia who have severe difficulty communicating. Pre-Therapy aims to facilitate engagement and create relationships with people who are traditionally seen as beyond contact or out of reach. The approach involves using contact reflections. The worker reflects back to the person their words, facial expressions, actions and surroundings. Until now, the application of Pre-Therapy to dementia care has not been explored in depth. An Action Research process examined the research question - What happens when staff learn and use Pre-Therapy contact reflections with people with dementia? The question involved three aspects: the response of people with dementia to contact work, the use of contact work by staff, and the learning process undergone by staff. Underpinned by values of inclusion, participation, democracy and collaboration, the study demonstrates joint inquiry and cyclical exploration. The research process involved self-participation, participation with health care staff and engagement with an expert community (The International Pre-Therapy Network). The entire research process spanned five years. Eleven staff in three residential settings participated as colearners for 18 months of the process. Located in the real world context, the study accommodated organisational flux, service instability and changes of personnel in a climate of modernization and reorganisation. Data were generated through observation, which included 14 hours of video recordings of interactions, and ongoing dialogue with health care staff and the expert community. The analytic process accompanied the research activity, using comparative analysis and Schatzman's Dimensional Analysis. Findings indicate that Pre-Therapy Contact Work has the potential to add to existing approaches in dementia care, facilitating greater self-expression of the experience of the subjective world of the person with dementia and promoting greater communication with workers. However, minor adaptations of the approach are indicated. Despite the apparent simplicity, contact work challenged staff. Barriers to learning and using contact work arose from intrapersonal, interpersonal and contextual factors. Factors which mediated the learning and use of contact work led to the emergence of a theoretical model of the emotional management of interactions. Resting on theories of constructed role identities, the model contains two contrasting positions: the emotional custodian and the emotional container. The thesis proposes that the model may be part of an underlying social process around maintaining emotional social order in interactions with people with dementia. In turn, this may help understand difficulties workers face when engaging in the emotional world of people with dementia and enacting values of being person-centred which are inherent in the policy and literature.

This study examines complex areas of nursing practice in secure mental health care, offering historical and contextual analyses of these highly politicised services. A survey design is used to consider educational preparation of nurses working in these settings; and to define competencies required by those working at varying levels of security. Data from focus groups (N=19) and interviews (N'24) with key service and educational personnel were content-analysed to yield a theory of nursing in secure environments comprising of an overarching definition incorporating eleven key themes supported by forty-five-statements of competency. The theory was translated into a questionnaire and distributed to national samples of nursing staff working in high, medium and low security environments (N852) for testing. Respondents (N=276) stated whether individual competencies were part of their current practice or supervisory involvement; and the degree of importance they accorded to each competency. Findings suggest that the theory proposed is strongly supported by nurses working within all levels of secure mental health services in the UK. This study also suggests that the preparation of nurses to work in secure mental health care is deficient at pre-registration, induction and postregistration levels. Students attending pre-registration placements were poorly prepared by educational staff who generally knew little of the specialty. In many instances, these placements also failed to make explicit the intended learning outcomes. Induction and post-registration training tended to be ad hoc; was frequently deficient in basic safety standards; and seldom skills-based. The competence framework received widespread support from nurses at all levels of security in relation to their level of importance. Perceptions of specific competencies in relation to role perfonnance varied with level of security regarding nurses' involvement with the patient's family; patient's preparation for transfer and support following discharge; and involvement with patient's local community. Results identified issues in relation to security and how procedures in parts of the system - notably in high security - militate against therapeutic care. Noticeable differences emerged between respondents working in high and medium secure environments. Issues of concern common to all levels of security included teamwork; balancing security and therapy; boundaries of professional practice; and clinical supervision. Conclusions suggest that the proposed competence framework provides an appropriate infrastructure for development of nursing in secure mental health care. It has clear implications for educational preparation of nurses, providing a suggested curriculum at pre-registration, induction and post-registration levels. It also encourages service planners to utilise competencybased job descriptions and focus staff development within their services more precisely.

Ovarian cancer is the second most common gynaecologic malignancy and the leading cause of death from gynaecologic cancer. Only one fifth of women present with an early stage (stages I or II) of the disease, whereas the remainder have an advanced stage (stages HI or IV) of the disease at the time of diagnosis. Although a significant improvement in response rate has occurred with the advent of platinum or Taxol based chemotherapy, there has not been a marked improvement in survival. These therapies often fail because tumour cells acquire resistance to therapy through mutation: and altered expression of cellular genes. The aim of this project was to investigate a radiation treatment regime that could overcome the clinical problem of radioresistance. Recently, it has been shown in cell survival studies that low doses of radiation (less than 100cGy) induce an initial phase of hypersensitivity (HRS) to radiation in vitro. This HRS is most pronounced in radioresistant cells. A treatment regime involving 0.5 Gy radiation dose given 4 times with 8 hour intervals between doses, delivered alone and in combination with the chemotherapeutic agent Taxotere was effective in both radiosensitive (BO-!) and radioresistant (SW626) cell lines. This low dose fractionated treatment (LDFRT) was effective in reducing cellular surviving fractions of these cell lines irrespective of the cellularp53 status. The molecular mechanism for LDFRT mediated sensitisation was investigated through the use of a protein DNA array. It was observed that an estrogen response element (ERE) and one of its target genes, Lipocalin 2, which is known to be involved in the growth and differentiation of cells, were not induced as a result of LDFRT, but induction was observed after treatment with a single dose of 2 Gy radiation. This observation indicates a possible molecular mechanism whereby LDFRT is more effective than single dose radiation in overcoming radioresistance. This project potentially represents a major paradigm shift in radiation delivery, which could significantly impact on future treatment strategies for ovarian and other cancers.

This thesis recounts an innovative critical exploration of accounts of child and adolescent mental health (CAMH); sourced from young people's Internet newsgroup contributions and academic/professional publications (both viewed equally as 'data' sources). An original discursive approach, informed by the concerns of 'postmodernism', 'constructionism', 'discourse analysis' and 'narrative inquiry', was developed and employed. Commencing with historical accounts of CAMH, an 'unconventional account' is presented which reads that history in terms of 'marketing'. Considering young people's Internet newsgroup accounts of CAMH as possible 'resistance' to conventional CAMH accounts, investigation into the types of post contributed and the subjects of interest being discussed indicated that self-injury/suicide were of particular interest to young people. Consequently, further in-depth critical investigation of young peoples' accounts of self-injury/suicide followed; comparing their accounts with the received wisdom found in the academic/professional literature. Outcomes indicate that three major themes run through the young people's contributions regarding self-injury/suicide; namely, 'change', 'control' and 'relationship'. Marked agreements between the newsgroup material and the academic/professional literature were established. However, significant differences were also discerned. Young people who selfinjure/ suicide ubiquitously described wishing to 'change' their thoughts/actions; in contradistinction to academic/professional wisdom that questions the genuineness of that desire, viewing such young people as 'difficult clients'. A number of 'questionable arguments' were also highlighted within the existing academic/professional literature. It is proposed that enhanced understanding of CAMEl accounts and their effects challenges the 'individualising' within existing discourses/narratives of young people who selfinjure/ suicide. Implications for enhancing theory/research and care practice are also discussed.

When asked mental health nurses consistently report relatively high levels of occupational stress, these levels of occupational stress are seen as affecting staff retention and also as creating a barrier to the ongoing improvement programme in mental health care. Previous research suggests that the 'critical factors' in the nurses' ability to cope with occupational stress are the personality variables that are considered to have consistency over the individual's biographical history and which are commonly described as dispositions or traits. Researchers who have examined this area argue that the limits implicit in the dominant approach to studying this area (selfreport questionnaires) are now restricting understanding of these personality variables and there are repeated calls for studies to use more sophisticated methods of data collection and analysis. Using an in-depth method of interviewing this study encouraged nurses in two radically contrasting settings (a therapeutic community and an acute admissions ward) to describe their experiences of stress both within the work environment and from the wider context of their biographical history. The aim of this biographical and comparative approach was twofold: firstly to examine whether the individual's biographical history affected their experiences of occupational stress, and secondly to explore the contrasting occupational environments from the individual's perspective with the aim of exploring whether the individual's experience of the institutional 'culture' affected their experiences of stress. Within the therapeutic community the psychodynamic model (the culturally sanctioned discourse) that underpinned the approach to treatment was almost exclusively drawn on by staff as an explanation for personal and professional 'stressful' experiences. This study indicates that this 'meaningful' explanation of suffering corresponds to the meaning orientated nature of the staff s biographical narratives. This meaningful explanation of suffering appeared acceptable to staff with many of the staff within this setting remaining at the therapeutic community for long periods. Within the acute ward whilst there was still some indication that the biographical narratives were meaning orientated there was less engagement with the culturally sanctioned explanation of mental suffering. The interviewee's narratives suggest that the staff coped with stress through [tacitly] conceiving of this setting as somewhere they would remain for a limited period of time. It is suggested that this tacit assumption is generalisable to other acute wards as a pattern of high staff turnover appears commonplace. These potentially generalisable findings have significant implications for the occupational stress experienced by mental health nurses and potentially wider implications for nursing practice: Firstly, management of stress in acute settings appears to demand a long-term view that both acknowledges the individual's biographical history and accommodates how nurses are socialised to view the professional role. Secondly, the plan to develop expert practitioners in the acute sector demands recognition that mental health nursing draws on the individual's 'meaning' based understanding of what mental illness represents as this meaningful understanding appears to contribute significantly to the individual's commitment to their professional position.

Older people residing in nursing homes have complex needs requiring the input of nurses skilled in managing multi-morbidities and psychosocial issues. However, in England, nursing homes have proven to be unappealing work settings for potential staff, while nurses who do work in these settings are often afforded low status. Such contradictions pervade current understanding of the nature of work in nursing homes. To-date, few studies have investigated the views and experiences of nursing home nurses themselves regarding the contradictions that arise from role and status issues. This study explores English nursing home nurses’ views regarding status and role. The aims of the study were constructed as follows:  To explore the experiences and views of nursing home nurses working with older people regarding their status and role. -To generate an understanding of how and why these experiences and views occur. -To explore whether emerging insights regarding nursing home nursing can inform workforce development processes. The methodology utilised was hermeneutic phenomenology, based upon the philosophies of Gadamer and Iser. Thirteen nurses from seven nursing homes were each interviewed five times using an episodic interview technique. Data analysis methods were adapted from Van Manen’s hermeneutic phenomenological approach, and Iser’s literary reception theory methods. Four categories emerged from the data - nursing ‘residents’ rather than ‘patients’, business role, stigma, and isolation and exclusion. From these categories, three themes were ascertained - uncertainty about role identity, unpreparedness for the demands of the role, and low occupational status. Participants feel uncertain, unprepared and stigmatised because they are positioned at the intersection of health and social care – a location where health and social care funding issues cross, and healthcare and social care work overlaps. Understanding generated from this study can inform workforce development processes.