The detoxification of free radicals at a cellular level is crucial for maintaining cell viability. The progressive loss of motor neurones associated with motor neurone disease (MND) may be due to acute or chronic free radical damage causing irreversible cell lesions. Perturbation in the mechanisms involved in the cell's protection against the deleterious effects of free radicals could therefore initiate, or indeed propagate, this damage. Measurement of the free radical detoxif'ing enzymes superoxide dismutases (copper/zinc superoxide dismutase (SOD I), manganese superoxide dismutase (SOD2), glutathione peroxidase (GSHPx) and catalase (CAT) at the site of motor neurone loss (i.e. the anterior horn in the spinal cord) showed a significant increase in the percentage of SOD2, in MND patients than controls, at the thoracic level. GSHPX activity was approximately 10-fold higher in the white matter of the spinal cord compared to that in the gray matter, whilst CAT activity was approximately 100-fold higher than GSHPX and equally distributed between the white and gray matter of the spinal cord. The activity of CAT within the central nervous system (CNS) is compartmentalised in microperoxisomes, it is therefore likely that removal of peroxides from the cytoplasm and other cellular organelles is reliant on GSHPx activity, which has a significantly lower activity in the anterior horn of the spinal cord than in other cells. Xanthine oxidase (XO) activity is a potential source of superoxide (07) (metabolism of xanthine to uric acid by XO produces 07) its subcellular location in the perikatyon of the spinal cord was shown to be associated with mitochondria. Thus the normal generation of 07 accompanied by alteration in superoxide dismutation may lead to increased free radical damage of the mitochondria which might initiate the process of cell death. 8-Hydroxylation of guanosine (indicative of oxidative damage) within the spinal cord from MIND patients was 10-fold higher than that in controls, showing that the nerve perikaiyon in MIND are subject to increased oxidative damage. It is clear therefore that free radical mechanisms play an important role in MIND.

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Objectives: To evaluate the effectiveness of art psychotherapy with adult offenders who have intellectual and developmental disabilities within an inpatient setting. The research looked at significant events taking place within the treatment that supported therapeutic outcomes. The aims of the research were to investigate a range of explanations for measurable therapeutic change that could be plausibly related to the processes observed in therapy. Design: Four single-case studies were conducted with pre-treatment, treatment, and post treatment assessment using multiple measures of change and observations of process. Participants: Four male participants with mild intellectual and developmental disabilities from an NHS medium-low secure forensic hospital in the UK. Intervention: Each participant completed up to 20 individual art psychotherapy sessions within six months. The treatment sought to engage each participant in making personally generated art work which was then discussed with the therapist. Main outcome measures: Core Conflictual Relationship Theme (CCRT); Daily Self-Rating Scale for specific symptoms; Personal Problem Scale; Modified Overt Aggression Scale (MOAS); Brief Symptom Inventory 18 (BSI-18); Glasgow Anxiety Scale for adults with Intellectual Disabilities (GAS-ID); Glasgow Depression Scale for people with a Learning Disability (GDS-LD); Rosenberg Self-Esteem Scale (RSES). Results: The main outcomes show a post-treatment reduction in aggressive styles of interacting with others for two participants in a medium secure unit. Daily Self-Rating Scale measures show an improved post-therapy trend for three participants, with all participants reporting improvement on the Personal Problem Scale and positive changes in CCRT interpersonal schemas. Behavioural and relational outcomes were observed to promote pro-social responses towards others three months following the end of treatment. Art psychotherapy was found to have positive therapeutic benefits for each of the four participants.

The prevention and appropriate professional response to children at risk of or experiencing child abuse and neglect has been identified as a national priority within the United Kingdom. Nurses (adult field) are likely to come into contact with children during their professional career and need to have the skills to detect and refer children who they suspect are suffering or at risk of suffering significant harm. However, there remains a dearth of evidence examining how nursing students (adult field) are prepared and supported and what their experiences are when they encounter child abuse or neglect in the clinical area. Therefore, the intentions of this study were: Research aim: To explore the experiences of student nurses (adult field) when they encounter what they perceive to be child abuse or neglect during their first community placement. Research questions: · How do student nurses (adult field) interpret, respond and learn from their experiences of encountering perceived child abuse or neglect during their first community placement? · How well are student nurses (adult field) prepared for encountering abuse and neglect? · How can they be better supported? Hermeneutic phenomenology was employed to guide the research design and processes, including data collection and analysis. The data were collected using narrative-style in-depth interviews from a purposeful self-selected sample of nine first-year nursing students (adult field) who perceived they had encountered child abuse or neglect during a community placement. Ethical approval was gained from the University ethics committee. Mezirow’s theory of transformational learning was used as a framework for analysis. Three overarching themes were identified: 1) Encountering disorienting events, 2) Reflecting on responses, assumptions and pre-conceptions and finally 3) An expanded worldview. The first theme reflected the student nurses’ initial thoughts as they encountered actual or perceived situations involving child abuse or neglect as well as deprivation. The second theme encompassed the student nurses’ initial feelings and responses to the experiences they encountered. This included feelings such as shock, anger, frustration and fear. Finally, the third theme outlined how the students reflect upon their practice experience, developing professional and personal insights. This is conceptualised as a transformational learning episode. The students’ journeys were idiosyncratic with variations in educational growth and transformation. The findings of this study suggest that student nurses (adult field) who encountered perceived child abuse or neglect during their first community placement felt unprepared for these encounters and would have welcomed the opportunity to reflect on their experiences when they returned to university. This has implications for the BSc Nursing studies (adult field) in considering the preparation and support of student nurses before, during and after their first community placement.

Background: Patient safety is of paramount importance in healthcare delivery. Following the inquiry into the Mid Staffordshire Health Trust (Francis 2013, 2015), there has been an increasing demand for nurses and other healthcare professionals to be open and candid in a transparent culture where harm and error are minimised. Despite this drive for openness, there is evidence that health care professionals remain reluctant to raise concerns and this includes student nurses as well as registrants. There is however paucity in research focusing upon the underlying factors which prevent student nurses from raising concerns about suboptimal practice. In an attempt to contribute to the discussion, this study will focus upon student nurses. Aim: The overall aim of this research is to understand student nurses’ perception of what they believe is a patient safety incident in their practice placements and understand the reasons that influence their willingness or reluctance to raise concerns about patient safety. Findings: Four main themes emerged from analysing the data: the context of patient safety; team culture; hierarchy and fear of retribution. Analysis and discussion of the data revealed that students were driven to raise concerns as they possessed strong moral and ethical beliefs to uphold patient safety. However, they had an overwhelming desire to fit in with their clinical colleagues and feared retribution and failure if they voiced concerns regarding care. This demonstrated that student nurses were subject to a fluctuating moral compass which was determined by psychological and sociological determinants. Conclusion: This research study has provided information which contributes to our understanding of student nurses’ beliefs about patient safety. It also helps us to recognise the factors that influence student nurses’ willingness or reluctance to speak up. This is important because with an increased understanding of their experiences and beliefs, we are better informed to broaden our teaching on this topic and develop effective policies to protect student nurses who raise concerns.

Professionalism can be a complex concept to define (McLachlan et al. 2002; Finn et al. 2009). Within nursing, the majority of studies have explored professionalism within the clinical environment, and very few examine how student nurses construct their talk regarding professionalism while they study at university, highlighting this as a distinct gap in the knowledge and understanding. The aim of this study was to uncover the discourses used by student nurses and lecturers, and offer insight into the influences on student professional language from within and outside of the nursing profession and offer an appreciation of the processes of language (discourse) adoption. The theoretical position adopted was social constructionism, where it is assumed we jointly construct our world on shared assumptions and that language is central to this process (Potter and Wetherell 2009). The methodological approach employed was Discourse and Social Psychology (DASP) (Potter and Wetherell 1987). Seventeen (17) interviews were conducted. Eight (8) of which were one-off interviews with lecturers. Seven (7) students from adult, child and mental health nursing were interviewed multiple times over the three years of their nursing programme. FIGURE 1 presents an overview of the research process. The analysis suggested that participants drew upon a number of interpretative repertoires and memes. These led to the identification of discursive threads, which were proposed as entangled within discursive knots, serving to position students and lecturers within a dynamic process of professional discourse development. The theoretical perspectives of Foucault, Goffman, Bourdieu and Harre informed the interpretation of the talk. Initially, students were positioned in a place of high surveillance through authoritative language used by lecturers. This position informed the discursive know of 'separation' which serves to maintain student nurses as 'different' and ‘special’, and to distance them from other university students. Clinical practice experience was seen as influencing students’ talk when back in University, emphasising differences. The discursive knot of 'maintaining quality and credibility' questions the 'real' place of nursing and the credibility of lecturers, and brings about a positioning of students that influences agency. The final discursive know of 'permission' is located in the talk of lecturers and final-year student nurses only. This knot illustrates students adopting the discourses of the registered nurse, including the surveillance talk used by lecturers to first-year students. This suggests that final-year students 'become' enforcers and protectors of 'difference'. This study highlights the intricacies and complexities of the 'professionalism discourses' woven into the talk of lecturers and nursing students, and their spread via both the overt and hidden curricula. Indeed, the adoption of the 'permission' discourse by third-year students suggests the perpetuation of a discourse via a socialisation process. The discursive 'knots' seem to function to instill, maintain and perpetuate wider discourses. The 'separation' and 'permission' knots may be viewed as serving to 'other' to maintain the 'specialness' of the profession, while the 'maintaining quality and credibility' knot may indicate tensions related to academic and clinical professional sub-groups and sites of knowledge development.

BACKGROUND: Each year approximately 350,000 women in the United Kingdom (UK) experience perineal suturing following childbirth. For those women whose perineal wound dehisces, the management will vary according to individual practitioner's preferences. For most women the wound will be managed expectantly (healing by secondary intention) whereas others may be offered re-suturing. However, there is limited scientific evidence and no clear guidelines to inform best practice. DESIGN: PREVIEW was a four-phase study, using a sequential range of quantitative and qualitative paradigms including: • A Cochrane systematic review (phase 1) • A comparative retrospective case note audit (phase 2) • A national electronic survey (phase 3) • A multi-centre pilot and feasibility randomised controlled trial (RCT) (phase 4, part 1) and semi-structured interviews with women who participated in the RCT (phase 4, part 2). Phase four was the main component of the study. AIMS AND OBJECTIVES: Phase 1: • Evidence synthesis for the therapeutic effectiveness of secondary suturing of dehisced perineal wounds following childbirth compared to non-suturing. Phase 2: • Explore risk factors associated with perineal wound dehiscence, with the use of a logistic regression model. Phase 3: • Survey current practice relating to the current management of dehisced perineal wounds from a representative cohort of RCOG members. Phase 4: • Establish the feasibility of conducting a definitive RCT comparing re-suturing of dehisced perineal wounds versus expectant management. • Provide preliminary evidence of the effectiveness of re-suturing versus expectant management for dehisced perineal wounds following childbirth. • Explore women's experiences of living with a dehisced perineal wound. METHODS: Phase 1: A systematic review of RCTs investigating re-suturing versus expectancy for dehisced perineal wounds following childbirth. This was conducted in accordance with Cochrane guidance. Phase 2: Case notes from women with perineal wound dehiscence (n=100) were compared with case notes from women with no dehiscence (n=100) using an audit tool developed in accordance with NHS Litigation Authority guidance. Phase 3: National electronic survey of members of the Royal College of Obstetricians and Gynaecologists. Phase 4: A mixed methods study where participants with a dehisced perineal wound were recruited to one of ten participating centres and randomised to either re-suturing or expectant management. The primary outcome for the RCT was time taken to heal. The secondary outcomes were: pain, dyspareunia, women's satisfaction with the aesthetic results of healing and breast feeding. A purposive sample of women who participated in the RCT were interviewed for the qualitative study. RESULTS: Phase 1: The Cochrane systematic review (2 studies n=52 women) recommended that there was an urgent need for a robust randomised trial to fully evaluate the comparative effects of both treatment options. Phase 2: The audit (n=200 case notes) revealed that episiotomy was an increased risk factor for perineal wound dehiscence. Phase 3: The national survey (n=53 respondents) confirmed the lack of evidence based guidelines to support clinical practice. Phase 4: The mixed methods study revealed a number of feasibility issues, particularly relating to a strong patient preference for a treatment option and researcher/clinician engagement at recruiting centres which would need careful consideration before proceeding to a definitive study. Thirty four women were randomised in the pilot RCT (17 in each arm). A further 95 women were eligible but not randomised. Data from 33 women were analysed on an intention to treat analysis. There was a trend for increased wound healing at 2 weeks following randomisation, Odds Ratio (OR) 20.00 95% Confidence Interval (CI) (2.04, 196.37) P = 0.004 but no difference at 6 weeks. Findings from the interviews (n=6) revealed 4 emerging themes: physical impact, psychosocial impact, sexual impact, satisfaction with healing and an 'a priori' theme participating in the RCT. CONCLUSIONS: This study has contributed to the paucity of literature surrounding perineal wound dehiscence. The results of the RCT should be interpreted with some caution due to the relatively small numbers included in the final analysis, mostly due to patient preference for a treatment option. However, there was a significant trend to favour re-suturing for the primary outcome measure of wound healing and the overall findings of phase four show that a further study is feasible. Furthermore, data from this study will be included in future updates of the Cochrane review published in 2013 and presented in chapter three of this thesis.

Central to successful therapeutic relationships in working with people with a learning disability is the language used by nurses; the discourses which they create and perpetuate; and resultant implications for practice. These are key issues in the current investigation. Employing retrospective data obtained during an action research programme carried out in a medium security forensic unit (MSU), it analyse types of discourse employed by the men who reside there and the staff. Part of the analysis shows having a learning disability as viewed through the eyes of the men themselves in a study extending over twenty months. Literary analyses on method, representations of learning disabilities, security and discipline, and forensic practice were carried out concurrently. Aims These are to (1) develop a critical and a post-modern approach to investigating given 'truths' about; the positives of learning disability; men with learning disability who offend; and the nature of forensic nursing: (2) develop a socio-political overview by applying critical discourse analysis to examine micro discourses and macro models associated with learning disabilities, related national and local policies, and models of nursing and disability: (3) combine the products of (1) and (2) to illustrate discourse, repertoires, paradoxes and practical ideologies justifying treatment in the MSU, revealing ideologies and beliefs regarding learning disabilities in this setting. Theory and method Foucault shows how linguistic constructions, written protocols and customary oral dialogue are used to create and sustain dominant views of 'reality' — and may also be used to challenge these. Retrospective data regarding six men living in the MSU and their staff [total N=17] were obtained using diaries, observational notes, semi-structured interviews, focus groups and evaluations originally collected as part of an action research project. National and local policies were also interrogated. Data were then reanalysed using critical discourse-analytic techniques. Outcomes Findings suggest that the men are viewed paradoxically. On one hand, they are seen negatively as different, dangerous, lacking ability: and staff as custodians restricting their rights. Paradoxically, affirmative discourse is also abundant — the men are talented and pleasant companions. Repertoires illustrate warm therapeutic relationships existing between the men and staff, demonstrating 'good nurse' characteristics expressed within a complex and restrictive environment, with humour playing an important part. These paradoxical repertoires reveal practical ideologies which defend forensic practice and justify treatment. Results have implications for the men (their views are acknowledged and disseminated); for practice through enhancing the evidence base; for nurse education through reflection on ideologies and justifications on which forensic practice is based.

As part of a high quality nursing student experience within Higher Education there is a need to access the voice of the student. By listening to the students, greater clarity and understanding from the students' perspective is proposed. The focus of this research is within the first year of an undergraduate nursing programme. This thesis gives insight into the experiences and perceptions of undergraduate nursing students' transition into Higher Education and professional transformation, within the first year of a three year proframme. In addition, the research sought to illuminate the participants' personal learning journeys and experiences. There is a dearth of literature addressing various aspects of the first year student experience and minimal literature which represents the student voice. The first year experience is a complex and multifaceted area of study. This complexity is related to the Higher Education organisational processes that are required to enable the student to succeed and the amount of personal investment by each student who enters programmes of learning within a university setting. It has been identified that the first year is the most critical to ensuring that students engage with programmes of learning and achieve both academically and professionally (Trotter and Roberts 2006). To develop insight into the learner's journey a theoretical framework is constructed from within an interpretive paradigm. Hermeneutic phenomenology was selected as a suitable methodology for this research, informed by the work of Max van Manen (1990). The use of hermeneutic phenomenology enable the exploration of participants' experiences. The participants in this research were representative of a typical nursing cohort's profile and, therefore, provided the ideal means of investigating the student nurse experience within the first year. Ten student nurses volunteered to participate in this research and data was collected over a period of one year by use of repeated semi-structured interviews and collection of critical incidents using digital voice recorders. Data was analysed using phenomenological and hermeneutic strategies involving in-depth, iterative reading and interpretation to identify themes in the data. Findings from this research identify that the students have developed skills to survive but there was considerable variation in the student experience which impacted on their motivaton and behaviour. A key finding was the ability of students to develop their own skills of coping to deal with the demands of academic life and those of the practice settings. The skills of self-reliance and self efficacy are evident in the findings and are explored in relation to professional transformation.

In the Irish healthcare system ward staffing is not matched with client acuity. With the recession came a moratorium on staffing and this combined with reduced length of stay for clients impacted significantly on nursing staff. Added to this a large number of front-line staff took early retirement leading to burnout of existing staff. Clear guidelines have been laid down by HIQA (2012a, 2012b) on the appropriate governance structure to ensure that client care is delivered safely and is of a high quality. The environment where nursing students undertake their clinical placement can have a positive or negative effect on them depending on the ratio of staff nurses to clients. The undergraduate nursing degree programme has been in place in Ireland since 2002. Nursing students register their qualifications with Bord Altranais agus Cnáimhseachais na hÉireann (Nursing and Midwifery Board, Ireland) upon successful completion of the programme. Nursing students are supported and facilitated on clinical placement by a qualified staff nurse named a preceptor. The term “preceptor” is the term used in Ireland to refer to a registered nurse who supports, guides and assesses nursing students on practice placement; the terms “mentor”, “practice placement supervisor” and “clinical supervisor” are also used in the literature to refer to the same role (Mead, 2012). For the purposes of this study the term “preceptor” will be used throughout this document. The quality of the nursing programme depends on the experience and level of supervision the nursing students receive in the clinical learning environment. This qualitative study explored current standards of the preceptorship model of nursing, to determine how preceptors perceive their role and the values preceptees place on the level of support they receive from preceptors during their clinical placements. I also needed to determine the level of support and training preceptors received from lecturers in higher education and management in the teaching hospital. The theoretical frameworks I used in the study were the Legitimate Peripheral Participation Theory (Lave and Wenger, 1991), which describes how newcomers become experienced members and eventually old-timers of a community of practice, and Social Learning Theory (Bandura, 1977), which proposes that learning takes place as a result of social interaction with other staff, including preceptors, through both verbal and non-verbal language. The literature implied that the role of the preceptor is stressful and the training inadequate (Haggerty et al., 2012; Eley, 2010; McCarthy and Murphy, 2010). This study set out to explore the tripartite relationship between preceptors, nursing students and lecturers. Using a qualitative approach, I conducted 24 semi-structured interviews with nursing students (n=8), preceptors (n=8) and lecturers (n=8). The study findings suggested that the preceptor’s role is difficult owing to time constraints, ward acuity and lack of resources. Part of the remit of a nurse working on a ward necessitates working different shifts and preceptors identified that it can be difficult to match the duty of a staff nurse with that of a nursing student. Preceptors found it challenging to give enough quality time to the students. Client care is always a priority with staff nurses, and must come first; the time they can spend with nursing students therefore tended to be ad hoc in nature. According to the preceptors they need on-going support from management of the hospital and lecturers in higher education. Those interviewed suggested they loved their role but felt they could not give enough quality time to the students. They would like more support from clinical placement coordinators (CPCs), from lecturers in higher education, and from management of the hospital. The preceptors also suggested that the training they receive needs to be more comprehensive, and to include more refreshers on curricula, teaching and assessing nursing students and providing feedback. The nursing students valued the time they spent with their preceptor, but this was sometimes limited owing to resources, ward acuity and working different shifts. They latched on to any available nurse when their preceptor was busy elsewhere or off duty. Overall, they would much prefer to have their named preceptor with them for support and guidance and because the preceptor was their assessor for their final interview on the clinical placement. The lecturers acknowledged the wonderful work the preceptors do in facilitating the nursing students in the clinical area. They believed that the preceptors should be given more support in the form of refreshers and “protected time” to precept the students. The lecturers would like to be more visible in the clinical area, but because of their teaching, research and administrative role their time is limited to quick visits to the ward. Some lecturers acknowledged that to remain current it is important for them to spend more time in the clinical area. Preceptors, employed by health care institutions, undertake the responsibility of supporting nursing students without protected time or remuneration. The nursing students are also supported by clinical placement co-ordinators (CPCs) on a 1 : 30 ratio. CPCs are employed by health care institutions to co-ordinate clinical placements. They assist with teaching and learning of students but do not formally assess them. They were not included in this study as there were insufficient numbers to match the sample size. To conclude, if there is insufficient time to precept nursing this can be a lost learning opportunity for the students. The nursing students miss the direct support and feedback from their preceptor and their learning is limited. They can finish their clinical placement not having reached their potential and maximised their learning. Despite the current climate of austerity there is a need to retain our highly qualified and capable nursing workforce.