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This thesis focuses on child and adolescent mental health. Epidemiological studies show that in order to manage the high prevalence of Child and Adolescent Mental Health (CAMH) problems within the finite resources of CAMH services, it is necessary to develop innovative practice research and development. Research and literature in CAMH is dominated by the quantitative paradigm rather than participative and qualitative approaches. However, research indicates that although evidence based strategies, derived from this research perspective, such as manualised parenting programmes, can be effective for children with challenging behaviours, that the most vulnerable parents are the most difficult to engage and maintain within community parenting programmes. This thesis takes a practitioner research perspective in order to work collaboratively with a small population of vulnerable parents, whose children have challenging behaviours that are interfering with the family's everyday life and impacting on the child's ability to meet their social, emotional and developmental goals. It builds upon a previous research project with nurses in a residential setting. The nursing project identified a specialist set of knowledge and skills, which were found to be useful in informing 24 hour care provision for children in a residential CAMH Unit and improving the behavioural outcomes for the children being looked after. The nurses' role overlaps with parents in the provision of 24 hour care, but the extent to which this nursing knowledge learnt in the previous study can be used by parents to maintain improvements in children's behaviour was not known. This thesis used a combination of qualitative methods within a participative action research approach and a critical theory perspective to engage in emancipatory research with parents as co-researchers. Action research starts from the premise that the solution to our problems are in our own hands and knowledge and understanding can only be developed through an exploration and learning from our everyday experiences. This thesis set out to learn:(1) Whether the nursing knowledge, derived from the nursing project, is transferable to parents in their community setting, and useful to parents when Caring for their children with challenging behaviours in maintaining and improving behavioural outcomes.(2) Whether parents can refine and develop the nursing knowledge and so add to a cumulative body of practice knowledge related to the 24 hour care of children with challenging behaviours(3) Whether gaining access to this knowledge as participants within the research process can increase the potential capacity of parents to be able to respond to their children(4) Whether the knowledge and potential capacity of the wider system providers and policy makers can be increased through access to the parents' knowledge, expertise and experiences in caring for children with challenging behaviours. In undertaking this research it is important to distinguish between the practice development and the research process. Action research is used to distinguish the two processes. The practice development incorporates an action research cycle which enables a learning process to occur in which new knowledge can be produced that can be subsequently theorised. Theorisation is used to critique the oppressive care processes produced by the medical model and to theorise alternative practice processes that can be used to overcome the oppression inherent in the medical model and increase the effectiveness of CAMH services. Twenty-five parents met the sampling criteria by engaging in at least one action research cycle. The action research cycles were used to explore extent to which the nursing knowledge and skills were transferable to parents in a community setting. Critical incidents were used to explore the parents' experiences of knowledge transfer. The findings illustrated that the transfer of the nursing knowledge to parents was useful, but not sufficient to increase the parents' capacity to respond to their child's needs because of a complex range of socio-political factors that differentially impacted on the parents' lives, compared to the nurses in the residential setting. This included isolation, guilt, housing and socioeconomic factors. In addition, the parents identified that they were subject to a range of oppressive forces that potentially reduced their capacity to respond to their children. Many of these tacit forces were found to be embedded in the medical discourse around CAMH practice and include a tendency to engage in the professional hegemony of knowledge, which legitimates the power of professionals to define the norms of behaviour in ways that can be oppressive towards and pathologising of vulnerable groups of children, who may not conform to a narrow construction of behavioural norms and the tacit idealisation and devaluation of carers. Together these can provide a rationale for blaming parents and for investing in services designed to improve parenting competencies whilst not having to address the wider socio-political determinants of child behaviour. The research findings indicate that challenging these oppressive assumptions within a supportive group setting, in which the parents actively participated in the research process, helped the parents to challenge and in some cases to transform their situation and that of their child. In keeping with a participative action research, the findings from the collaborative research with the parents are synthesised into a practice framework, which represents the emerging action plan. A critical analysis of the opportunities and constraints for implementing this action plan is provided. The research demonstrates that engaging in participative research with clients whilst also engaged in practice is a complex and problematic process, which requires an innovative combination of methods but which can produce new and innovative ways of theorising practice processes and outcomes. Through the research process described in this thesis the oppressive nature of many well-intentioned aspects of CAMH practice are revealed and theorised. In taking this analysis forward practice processes and outcomes are theorised in the context of both the medical and social models of health. The research demonstrates how these two models can be integrated in practice and how the process of integration has the potential to enable the development of a cumulative and integrative body of emancipatory practice knowledge, which acknowledges and addresses the complexity, uncertainly and unpredictability of clients 24 hour experiences but at the same time maximises the total set of resources available to both support families and also to widen the capacity of professionals and service providers to develop insightful and non-oppressive solutions.

Great debate surrounds the issue of patients with breast cancer participating in surgical/medical decision making and their ability to give an informed consent. Health care professionals must balance the need to safeguard the rights of patients, respect their autonomy and yet be sensitive to the changes and individual variations a patient may demonstrate as they progress from diagnosis to the end point of their disease. The premise underpinning the study and literature review, reflected in the published works presented here, focuses on a woman's right to access, should she choose, accurate information to make an informed treatment choice based on an exploration of the literature which reviews the ethical issues including autonomy, informed consent, advocacy, communication, access to information, approaches to shared decision making, psychiatric morbidity and evidence based medicine. Objectives of the Study Reflected in the Published Work Presented Here: 1. To determine the acceptability of an interactive video system, in addition to the standard informational care and support provided by the clinicians and clinical nurse specialist, as a means of providing information about the risks and benefits of treatment choices-surgery and subsequent adjuvent chemotherapy - to women with early breast cancer who are facing choices about treating their early breast cancer. 2. To determine whether providing information to women with early breast cancer using an interactive system significantly reduces anxiety and depression associated with the diagnosis and treatment of this condition. 3. To determine whether providing information using an interactive video system, to women about treatment choices significantly increases patient satisfaction with the choice they have made. To assess this for a two year period patients attending for surgical treatment for early breast cancer were recruited, after full discussion and written consent, into a randomised control trial to evaluate the acceptability and effectiveness of the interactive video system. Eligible patients (100)included all women with an early primary invasive breast cancer who had a genuine choice between treatment options.. Patients excluded from recruitment and viewing the Interactive Video (IVD)/Shared Decision - Making Programme (SDP) were all women who did not have a straightforward choice. All patients in the intervention group completed the following: a. Acceptability of the Interactive Video; b. Assessment of Health Status, The SF36 (Ware and Sherbourne 1992) c. The Hospital Anxiety and Depression (HAD) scale (Zigmond & Snaith 1983) After nine months the patients were again asked to complete the three questionnaires but at this point Questionnaire 1. elicits the patient's satisfaction with their treatment choice.

This thesis shed light on the complexities of dressing evaluation. Dressings are categorised as medical devices and as such manufacturers are not required to provide evidence of effectiveness. Instead, they promote their products by offering clinicians samples to try during their clinical work. Researchers using trial methodologies have been unable to provide a clinically helpful body of evidence. Placed within the movement critiquing Evidence-Based Practice, this thesis brings the discussion to the world of dressing evaluation, where an alternative methodology is proposed. This study takes inspiration from John Dewey’s pragmatic philosophy; based on experimentalism, clinician’s experience is given a key place within a structured inquiry and offers a vision for the development of this important branch of wound care. This offers a unique contribution to knowledge. In order to understand the world of dressing evaluation, the study begins with the collection of qualitative data, with focus group and interviews with seven Tissue Viability Nurses and two Pharmacists. Having gained an insight into the way dressing evaluations are undertaken in clinical practice, the data inform a subsequent, mixed-methods study, with participant observation, interviews and review of documents take place with ten patients, thirty-one nurses, one orthopaedic surgeon and five trauma sisters. Using this newly designed methodology, a PHMB foam dressing is evaluated in the care of pin sites, enabling the development of a clinical protocol that has since been adopted regionally. This offers a unique contribution to practice.

Background: The healthcare assistant (HCA) workforce delivers much of the fundamental care across both health and social care and is therefore in a unique position to influence the patient experience. To date, there has been little qualitative research that explores the HCA role from the perspective of the patient. Research Aim: The research set out to explore, and generate a theoretical understanding of, the role of the HCA from the patient perspective within secondary care. Research Design This study explores patients’ perceptions of the role of the HCA within secondary care. Ethical approval was granted in May 2014. Data were collected in a large teaching hospital in North East England between 2014 and 2015. Employing constructivist grounded theory, twenty patient interviews were coded and analysed. Three later interviews were added for depth to the findings. Findings: Four core categories emerged from the data: · Expectation Participants entered the healthcare environment with varying expectations but told a largely positive story about their experiences, reframing negative episodes within an overall positive narrative. This reframing may indicate participants were indirectly reinvesting in staff for their future care needs. · Observation: Some participants worked out “who was who” through observation, often associating tasks with uniform. Where jurisdiction and performance of the HCA was not as expected, this sometimes made participants more vigilant. · Meaningful connections Meaningful connections involved comfort and consideration from staff and humorous interactions between participants and HCAs. These connections contributed to the patienthood experience and were employed as a trading strategy, to cement relationships and overcome difficult circumstances. · Adaptation Participants worked out when to ask for help, recognising their dependency on staff availability and desire not to be labelled a nuisance. Conclusion: In conclusion, education and development for HCAs that enhances understanding of roles and performance and their impact on relationships with patients would enhance the patient experience. Implications Investigation of the negative patient episodes hidden within reframed positive narratives would inform future policy and educational initiatives.

Since the 1990s patient safety has been recognised as a major concern within healthcare worldwide, as well as within the National Health Service (NHS). There is evidence to suggest that contact with healthcare can cause avoidable harm and unnecessary death. In the literature, these significant safety failings have often been linked to the prevailing organisational culture in the NHS. However, the exact nature of this culture and its connection to maintaining patient safety is unclear, despite the reported implementation of strategies to improve patient safety across the healthcare system. As a key staff group within the NHS, nurses have a key role to play in protecting the public and keeping them safe. However, the lack of clarity relating to the links between culture and patient safety initiatives potentially compromises the degree to which nurses can have a positive influence. This qualitative study therefore aimed to better understand, from a nursing perspective, the links between organisational culture and the implementation of patient safety initiatives in one NHS Foundation Trust in England. The following research question provided a focus for the study: ‘How do top-down patient safety initiatives permeate through organisational culture within an NHS Foundation Trust’? A naturalistic inquiry methodology was used to gain an insight into the socially-constructed safety culture within the Trust. A purposive sampling method was used to recruit 16 participants. The sample comprised participants from the Trust executive team, the Trust operational management team, and 2 clinical ward teams, in order to capture staff perspectives from “board to ward”. Data collection included individual interviews and focus groups with the participants about patient safety generally, and their involvement in a selected range of patient safety initiatives including: falls, medications, infection, recognising the sick patient, and pressure sores. Data were collected via direct observation of participants’ practice in addition to a focus group and secondary data analysis of minutes from a range of Trust meetings. Thematic analysis of the data yielded seven themes: cultural consistency; safety initiatives and focus; communication; measurement; development; leading and shaping; and communities of practice. It was also evident from the analysis that only one of the five safety initiatives had fully permeated from board to ward (falls), demonstrating an inefficient flow of information through the Trust. The outcome of the study suggested that “climate”, rather than “culture”, was perhaps a more sensitive indicator of the receptivity of the ward team to the implementation of top-down patient safety initiatives in the NHS Trust studied. It is suggested that rather than focussing on the intangible notion of a “safety culture” as an indicator of safety risk, “safety climate” perhaps offers a more appropriate alternative. Assessing the safety climate of an organisation, and settings within it, offers the opportunity to focus on concrete issues such as nursing staff behaviour and communication mechanisms. This allows identification of organisational barriers to information permeation, and implementation of change. This, in turn, will improve the patient safety climate in the NHS.

Modern Matrons are at the vanguard of both care delivery and the NHS reforms and have an important role in the modernisation of, and future delivery of healthcare. An important contextual feature of their role and a concept that has been widely embraced by the National Health Service, is that of decentralized decision making. Unlike clinical decision making which has been extensively studied, there is little in the healthcare literature regarding leadership and management decision making or the concept of decentralised decision making. In order to maximise the effectiveness of the Modern Matron role, it is important that we gain a thorough understanding of how they make leadership and management decisions, the reality of the term decentralized decision making for them and an insight into their abilities and needs in regards to this essential skill.

It has long been documented that patients from lower socio-economic backgrounds do not access health services. There have been Government led initiatives to ask service users what they want from services to provide initiatives that will improve the health and well-being of the population. There has been little or no involvement of patients who do not access services to ask them why they do not attend or involve themselves in decision making. Previous studies into access to cardiac rehabilitation have been predominantly quantitative, with very little qualitative data to explore the reasons why people from lower socio-economic backgrounds do not access the programmes provided. In this study beliefs of people who have not accessed cardiac rehabilitation are explored with a group of participants who have a diagnosis of coronary heart disease using a Heideggerian phenomenological approach. Semi-structured interviews were used to collect data. Themes were identified using line by line analysis. Three case examples were described bringing the data back together into a whole transcript for further exploration. The key findings from the research showed that the participants, all from the five poorest electoral wards of Darlington highlighted what to them were the significant factors in their health journey. The most common themes were (1) support, (2) choices and risks, (3) cardiac rehabilitation inhibitors and (4) perceptions of what had happened to them. In conclusion the findings from this study can be used to stimulate a review of current thinking and practices among health professionals, educators and other agencies involved in supporting this group of individuals to meet their long-term adjustment needs. Long term cardiac rehabilitation provision could be further enhanced if future policy initiatives reflected the needs of this group of individuals, and further research into this area could be implemented.

South Asians living in the UK have an increased predisposition to developing Type 2 diabetes. Type 2 diabetes usually occurs later in life and has significant invisible long term risks that can affect an individual's quality of life and longevity but are preventable with life style changes. For people of South Asian origin, their perception of risks associated with Type 2 diabetes is likely to be shaped by a range of different factors, including cultural influences on gender roles, family life, and the significance of food and its preparation. The South Asian population in the United Kingdom is heterogeneous with strong socio cultural and religious beliefs that impact upon an individual's life style. Research on issues related to risk and risk perception have largely been conducted in developed countries. Models on risk perception have also evolved from these settings where people have increased personal autonomy, better resources and access to health care and related information. Risk is socially constructed and is influenced by socio cultural factors, religious beliefs and gender. Health related risks are understood differently by lay people and practitioners. Research available on risk perception among minority ethnic groups and the immigrant population living in a western context is very limited. Risk perception among South Asians with diabetes has not been explored in particular despite the escalating incidence of Type 2 diabetes in this population. This study aimed to explore how risks related to diabetes were perceived by older South Asians with Type 2 diabetes in the United Kingdom and developing a conceptual model on risk perception. A qualitative research design using grounded theory with its theoretical foundations drawn from Symbolic Interactionism was used. Data from two focus group interviews with ethnic health development workers, seven individual interviews with practitioners and twenty interviews with older South Asians with Type 2 diabetes was collected, transcribed and analysed. The process of Cross Language interpretation (Larson 1998) was used with gender and ethnically matched interpreters to collect data from non English speaking participants. Triangulation, audit trail, peer debrief and reflexivity were used to enhance rigour in the research process. Risk perception among older South Asians was interpreted in terms of risk awareness and risk engagement. Risk awareness was influenced by factors from within the cognitive and affective domains that resulted in risk engagement. Risk engagement was proactive if risk awareness was present and the locus of control was internal. Risk awareness involving the affective domain resulted in reactive risk engagement through risk response, ranking of risks, risk repair and creation of safety nets when influenced by external locus of control. The affective domain being predominant in comparison to the cognitive domain poses significant implications in the planning and provision of services to minority ethnic groups. The concept of concordance in diabetes management and the empowerment model that advocates self management towards risk prevention as the cornerstone of diabetes management may be challenging for both South Asians and their practitioners. This model on risk prevention that is largely oriented towards the cognitive domain requiring internal locus of control needs to be carefully evaluated in minority ethnic groups such as South Asians with Type 2 diabetes.

This study investigated the employment experience of younger people with Parkinson’s Disease (PD). The aims of this study were formulated from reflections on clinical practice and observation of the often detrimental impact caused by relinquishing employment. A steering group consisting mainly of younger people with PD was established to guide the project. A sequential transformative research design was chosen and three methods of data collection were utilised in a flexible, multi-method approach: a questionnaire, which was distributed nationally and in electronic format via the Parkinson’s Disease Society website; a series of three focus groups; and an electronic proforma which recorded the employment stories of respondents via a newly created website. The meaning that employment had for younger people with PD, benefits of working, the decision making process regarding leaving work, difficulties encountered and successful strategies used by younger people with PD to maintain their employment were explored. This study unveiled a narrative surrounding the experience of employment of younger people with PD. The results indicated that this group required targeted assistance to enable them to maintain employment. The results were therefore transformed into a seven staged intervention to facilitate the maintenance of employment and to alter the current narrative. The staged intervention was developed to address the key issues highlighted by the study. Respondents identified a lack of available information and had a poor awareness of employment rights. There was a consensus regarding difficult symptoms to cope with in employment with fatigue having the biggest impact and other symptoms being: cognitive changes, stress, anxiety, reduced dexterity and mobility. Lack of flexibility by employers was noted to contribute to difficulty in work, and dealing with customers or speaking in public were the most problematic work roles. Respondents identified the benefits of work as: mental stimulation, a sense of identity, self esteem and financial benefits, and felt that giving up work would contribute to a social withdrawal. Respondents found that interaction with non-specialist professionals, in relation to the maintenance of work, was ineffective. The study recommends that this intervention should be delivered by a specialist occupational therapist with access to the skills of a multi-disciplinary team. The intervention was tested in practice and an evaluation model was presented to enable further development.