Anomalies noticed in midwifery practice prompted a review of literature around progress in labour after Loop Excision of the Transformation Zone (LETZ). The previous research was equivocal. This study investigates the pattern and progress of women's labours following LETZ, and the effect of the experience on women. It also explores the basis of clinical decisions made by midwives. It takes place in North East England and involves women giving birth in 2004-2005. The case study strategy brings together quantitative retrospective case control results, qualitative analysis of semi-structured interviews from women and midwives, and guidelines and protocols surrounding assessment and management of labour. The quantitative data is from 111 women after LETZ and 214 controls, reducing to 94 and 150 respectively after removal of cases with confounding variables. Interviews are from four women, three individual midwives caring for one of the women and a focus group of four midwives. In the interviews, women gave no thought to how their births may be affected by LETZ, as no one had discussed the possibility with them. Women having their second baby after LETZ take less time to reach full dilatation; a result related to grade of Cervical Intraepithelial Neoplasia. Women having their first baby after LETZ are 1.8 times more likely to be admitted later in their labours, an important emergent issue that needs further research. Women having their first or second baby after LETZ are 2.3 times more likely to have a premature birth, confirming indications in previous research. This study for the first time reveals important differences in pattern and progress of labour after LETZ. It adds to our knowledge of premature birth after LETZ. Midwives, obstetricians and colposcopists need to incorporate the study results into counselling of women before LETZ and during any pregnancy after LETZ.

Innovations in cancer care requiring intensive support, and improved cancer patient survival in and out of critical care, have led to greater numbers of cancer patients than ever accessing critical care. Of these, however, a fair proportion will die. Current research points to around one in six patients dying in general critical care units and even higher numbers for cancer patients. End-of-life care (EOLC) for critically ill patients is problematic and rarely addressed beyond satisfaction or chart review studies, while palliative care is an established domain in cancer. It is not known whether dying, critically ill cancer patients experience good EOLC. In the context of a cancer critical care unit, this thesis explores the provision of EOLC for cancer patients in a critical care unit. Exploring measures for comfort care and palliative principles of care helped identify what is important for patients and families, and what those measures meant for all participants. The diagnosis of cancer and how it impacts on EOLC provision for critically ill cancer patients was also explored from the perspective of patients, families, doctors and nurses. A Heideggerian phenomenological interview approach was undertaken, in order to gain personal experiences. Families of those patients who died after decisions to forgo life-sustaining treatment (DFLSTs) were interviewed. Patients who have experienced critical care were also interviewed, since patients‘ views about EOL care provision are very rarely explored. Doctors and nurses also contribute their vision for, and experiences of, EOL care in a cancer critical care unit. Thirty one interviews with 37 participants were carried out. Cancer prognosis together with critical illness prognosis contributed to difficulties in deciding to move to, and enact EOLC. The nursing voice in DFLSTs was minimal and their role in EOLC depended on experience and confidence. Achieving a good death was possible through caring activities that made best use of technology to prevent prolonged dying. EOLC was an emotive experience. Decision-making and EOLC could be difficult to separate out which, in turn, affects prospects for EOLC. A continuum of dying in cancer critical illness is presented with different participants‘ experiences along that continuum. Three main themes included: Dual Prognostication; The Meaning of Decision-Making; and Care Practices at EOL: Choreographing a Good Death with two organising themes: Thinking the Unthinkable and Involvement in Care. These themes outlined the essence of moving along a continuum toward patients‘ deaths and the impact that had on opportunities for care and a good death. Nurses could use the care of patients dying in critical care as an opportunity to develop specialist knowledge and lead in care, but this requires mastery and reconciliation of both technology and EOLC. This work builds on Seymour‘s (2001) theory of a negotiated and natural death related to achieving a good death in critical care. Trajectories of dying, part of Seymour‘s (2001) theory, are extrapolated on with reference to Glaser and Strauss (1965) and Lofland (1978)‘s theories on dying trajectories. Nursing theory is developed through examination of Falk Rafael‘s (1996) and Locsin‘s (1998) theories of empowered caring. Implications and propositions are presented for nursing and wider practice around EOL care for critically ill cancer patients.

Examination of the literature suggests that relationships between psychiatric staff and the families of service-users are often characterized as unsatisfactory, and that psychiatric hospitals provide an unconducive environment for the implementation of family and network-orientated approaches. This research focused upon the development in an adult psychiatric admissions unit of family- staff network meetings, that occurred when a person entered hospital. These network meetings, or 'reception meetings', were strongly influenced by the Finnish social network approach (Seikkula, Alakare & Aaltonen 2001), which focuses upon the creation of open dialogue between the service-user, family members and professionals. An overall aim of the study was to generate a body of practice-based narrative accounts which might act as a catalyst to practice developments in this field. Drawing upon a postmodern methodological framework, a range of methods were employed to engage with the multiple voices of service-users, family members and staff in the research site. Data sources included semi-structured interviews, participant observation, secondary data, and material from a research diary that was maintained as a reflexive tool in relation to the practitioner research process. A 'voice-centred relational method' (Brown and Gilligan 1992) provided a heuristic device for guiding data interpretation which facilitated multiple readings from different perspectives. A subsequent stage of data-analysis entailed developing more general connecting themes from across the data-set. A number of themes are developed in the research, which principally relate to the tensions associated with the introduction of a relationally orientated, reflective approach to practice within an individually-based medico-psychiatric organizational context. Practice approaches are discussed which appeared to facilitate an ethos of 'safe uncertainty' (Mason 1993) within network meetings, which is a necessary condition for dialogue. Connections are also drawn between themes generated in this study and the broader contexts of government policy, professional and organizational development, and practice-based research.

Multiple Sclerosis (MS), the most common progressive neurological disease in young adults can take a relapsing remitting (RR) course especially in the early stages. There is a gap in knowledge in the application of self-management and self-efficacy with progressive long-term conditions. This research explored the experience of individuals with RRMS with particular focus on their attitudes to self-management and development of self-efficacy. The research addresses the question about engagement with self-management and self-efficacy influencing the journey of people with RRMS and their formal and informal carers. The research draws on the experiences, perspectives and understanding of the social processes and reality through interaction. Using grounded theory for generation of the themes captured from people with RRMS, their partners/carers and professionals involved in their care. The research design around a conceptual framework, used longitudinal studies capturing the experiences of people with RRMS and their partners/carers, through individual interviews and self-efficacy qualitative questionnaires over eight monthly meetings. The research sample of people with RRMS was three male and three female with an average age of 44.5 years, a mean duration with RRMS for 9.6 years. Professionals shared their perceptions and experiences through a focus group and individual interviews. Personal and reflective diaries kept by the researcher of events throughout the study enabled decision and audit trials to contribute to the rigour of the research. The data analysis has generated a number of themes that have been developed and presented throughout the thesis. The research process has generated new theory around the knowledge of and experiences of the three groups of research participants. Fluctuations of living with RRMS across roller coaster journeys, with transitional processes of daily changes and meanings brought threats and challenges. These highlight the importance of self-efficacy and self-control, of coping with uncertainty and unpredictability, through engaging with self-management behaviours. These enhanced perceptions of self- determination, positiveness, independence, quality of life and well-being. The transformation of uncertainty secured hope, opportunities and embracing RRMS through coping mechanisms and self-confidence. Formal and informal support was required where the People with RRMS deemed appropriate. The epistemological perspective has explored power as a multilayered and dynamic concept with different knowledge bases and issues that need addressing prior to successful partnership working. The research is original in terms of the groupings, the areas reviewed for this RRMS group and the potential for ongoing work, policy and practice changes both locally and nationally. Implications for practice, policy and further research were derived from the conclusions. In practice more empowerment, advice and information are required for people with RRMS to live independently. Policies for skills and knowledge training in these areas are required for shared decision-making and partnership working. Further research is required into utilisation of Integrated Care Management of ways of supporting independence, self-control and personalised plans for people with long- term conditions and their informal carers.

No description available.

No description available.

Background: There has been little research into the area of future disorientation in adults living with and beyond a cancer diagnosis. Research conducted in this area tends to focus on women who have been treated for gynaecological cancer and to be cross-sectional. Therefore, little is known about the impact of future disorientation on other groups of people living with and beyond cancer, including men, and little is known about how the experience may change over time. Aims: This thesis aims to develop a conceptual framework illustrating the experience of future disorientation. This was achieved by exploring what the consequence of future disorientation are, what factors cause participants to experience future disorientation and what factors prevent/reduce the impact of future disorientation. Methods: This study utilised an interpretative phenomenological analysis approach (IPA) which informed all aspects of the data collection and analysis process. Eight patients attending follow up clinics in the North East of England were recruited and were interviewed on two occasions six months apart. The interviews were semi-structured and analysed using an IPA approach. Results: The results of this study have shown that future disorientation can be experienced by men and women living with and beyond cancer, that it can persist over time, and have a number of consequences. A number of factors have been identified which may contribute to the experience of future disorientation such as cancer related fears, and anxiety. Furthermore a number of factors emerged which may protect patients from experiencing future disorientation, such as support networks and making lifestyle adjustments. This thesis constitutes an original contribution to knowledge as no work has previously sought to map out the conceptual framework of future disorientation or how it changes over time.

This thesis investigates the lives of seven disabled people who were sexually abused in childhood by utilising narrative methodology and the application of the social model of disability. Flexible methods of participation were offered to participants and continuous ethical evaluation formed the backbone of the research relationship. Thematic analysis generated three interlocking and overarching "grand" themes that constituted the substantive chapters of the thesis (power, identity and narrative) and provided a structure within which the findings were embedded. Narratives of power illustrate how the sexually abused disabled child is potentially located at the collision point of a number of oppressive societal beliefs and practices related to the treatment of both children and disabled individuals. These debilitating attitudes become apparent in the workings of certain organisational structures and the general functioning of some family environments. Narratives of identity deals with the issue of how a, sometimes, fragile identity created by disability oppression becomes fragmented by the sexual abuse experience. It also illustrates that from this compromised starting position, participants have been able to forge a series of self-affirming collective identities. The chapter entitled narratives of the narrative concerns itself, ostensibly, with the reconstruction of the abuse narrative. Within this chapter it can be seen that when the usual defence mechanisms (dissociation) become less necessary for survival, and when the external triggers are prevalent, the sexual abuse narrative emerges creating narrative chaos (Frank, 1995) and emotional destabilisation. The personal healing process has involved the reconstruction of a more reflective, self-absolving and coherent version of events, which contains narrative truth (Spence, 1994). In concluding this thesis, several tasks were undertaken including the weaving together of the complex relationship between disability and child sexual abuse, and a highlighting of the key pressure points where difficulties were exaggerated. It also involved: consideration of whether narrative methodology fulfilled its purpose, a reflection on the work's theoretical positioning and the implications of the thesis for policy and practice.

The overarching purpose of this research was to find out about life with Parkinson's disease and to use that knowledge to inform physiotherapy management. The project aimed to explore current and alternative ways in which professionals could seek to understand the experience of life with Parkinson's disease; to explore the implications of resultant new knowledge; and to investigate how physiotherapy relationships should take account of new ways of understanding and new knowledge. A spiral of research activity was undertaken comprising three successive cycles. The first two cycles were undertaken using case study methodology, focusing on the experience of life with Parkinson's disease from a group and an individual perspective. A wide range of qualitative and quantitative methods for both data collection (including interviews, disability and quality of life scales and activity monitoring) and data analysis were employed. The level and complexity of personal work undertaken by individuals to manage their condition was the principal theme to emerge from initial cycles. This insight led to the development of a tool — strategy mapping — to enable professionals to capture and use information about self- management in their interactions with individuals. The third cycle employed action research methodology to develop and evaluate the strategy mapping framework - centred on identifying strategies related to Self, Routines, Support and Involvement - in physiotherapy practice. A number of perspectives were developed in relation to the project's aims. The methodological perspective highlighted the need for commitment to listening to the experiential narrative and hearing the story of self-management. The ontological perspective offered the potential for practice and research to build on existing self- management solutions. The epistemological perspective pointed to addressing power differentials between knowledge bases to promote collaborative therapy relationships. The full potential of a paradigm shift which attempts to increase the degree of alignment between the everyday lives of individuals with Parkinson's disease and physiotherapy practice, education and research remains to be uncovered.

As the population of people in the UK, over 65, increases and the welfare system moves from a collectivist, towards a consumerist system, involving older people in their rehabilitation and care becomes more important. It is recognised that the effectiveness of practices to increase involvement varies. The reasons for this include the lack of clarity about the meaning of involvement in health care. The aims of this research were to develop a substantive theory, which explains the meaning of involvement for older people in their rehabilitation after acute illness and facilitates recommendations for health care practice development. Grounded theory was employed to collect longitudinal data from four older people, their practitioners and support staff, during the participants’ rehabilitation stay of around six weeks in an Intermediate Care unit in the UK and at home. Data were collected using recorded, semi-structured interviews and conversations, from December 2008 to November 2009 and were analysed qualitatively. The findings suggest that involvement in rehabilitation operates through an Involvement Attribute set consisting of two interdependent groups of Involvement Attributes (the psychologically-based and the action-based). Collectively, the Involvement Attributes are: the possession of a Vision, Incentive and Goals, a positive Disposition; a propensity for Cognitive Development; Goal planning, setting and achievement; and Risk Management. To be maximally involved the Involvement Attribute set has to be strong, balanced and with alignment between the two groups. Involvement in rehabilitation is also related to the type of relationships developed with the health care staff and relatives. Improvements in Involvement Attribute sets require a move away from paternalistic relationships towards the collaborative, partnerships suggested within relationship-centred care. In this way, involvement of older people in rehabilitation is: “A joint commitment within therapeutic relationships to determine and be determined in the pursuit of an Involvement Attribute set that is strong, balanced and aligned”.