Background - UK healthcare has adopted various improvement strategies from business including using satisfaction surveys. However, the way patients form and express judgements of quality care can be more complex than customer purchases. Research in adult patient satisfaction has found capturing patient opinion challenging; however, adult service- user views continue to underpin quality care guidance across healthcare. Development of knowledge to include parental views of quality care is important to inform future guidance specific to children’s services. Methods - This study aimed to examine how parents determined the quality of care provided when their child was hospitalised, factors influencing perceptions of care and whether these judgements changed over time. Using a grounded theory approach, data were collected through a series of in-depth interviews (22) with nine parents following their child’s hospitalisation. Findings - The substantive grounded theory - Parenting in an alien hospital world: on guard and on behalf offers new perspectives on the complex psychosocial processes underlying parents’ quality judgements. When their child was hospitalised parents landed in an ‘alien’ world but continued to try 'to parent' (protect and advocate) their child. Parents' experiences were characterised by landing; moving from being' new parents' to 'old hands'; searching for and judging the 'clues' and facing dilemmas of how best to respond to professionals. Parents were found to use an escalating level of signals to prompt health professionals to respond to their queries and concerns Parents' personal lens altered through their transitional journey and this, together with their perception of professionals' power impacted on their chosen responses to professionals and their quality judgements. Parents held two views of care quality: ‘at the time’ and a final ‘on balance’ view. The final view recognised their own heightened emotions and reflected their current transition. Conclusions - Ultimately parents judge hospital care as high quality when they perceived health professionals acted as their allies in their parenting roles as protectors and advocates for their child in the alien hospital world. Health professionals could improve parents' experiences and quality judgements of care by early recognition and response to their 'signalling' and by explicitly acting as parental allies.

Introduction: Cervical cancer is 11th most common cancer among young women in the UK. Early detection through screening is thought to have resulted in a 75% decrease in cervical cancer and saves over 4,500 lives each year. However, recent years have seen a continuous decline in screening uptake, especially among young women. Scientific literature reviews show little research in this area. There is therefore a need for a qualitative exploration into the reasons and motives for low uptake of cervical cancer screening from service users’ viewpoints in England. This study explores factors that influence the participation and non-participation of young women aged 25-34 in the NHS cervical cancer screening programme in the Northeast. Findings are expected to inform age-specific interventions aimed at increasing participation. Methodology: Employing the qualitative approach of grounded theory (GT) enabled the development of an understanding of participants’ behaviours and factors affecting participation, including health beliefs and other associations that influence the decision to attend screening. Twenty-four research participants were recruited purposively and theoretically from universities in the Northeast and a community centre in Newcastle, as well as through the Northeast Call and Recall Centre in accordance with ethical approval. Data was collected through semi-structured face-to-face interviews and a focus group session. The analysis was done using the GT techniques of the constant comparative method and theoretical sampling, aided by individual sorting and use of Mind Genius software. Findings: Awareness of cervical cancer prior to receiving a screening invitation was found to be relatively low and there was an overall lack of understanding of what the screening entails. There was no direct correlation between health beliefs and participation, however, health beliefs were influenced by cultural, environmental and social factors. The findings from both the interviews and the focus group led to the creation of three contextual categories, which are: health views relative to self; knowledge/awareness; and health service influences and practicalities associated with participation in cervical cancer screening. The three main categories and their subcategories were further conceptualized to create a core category, ‘sexual association’, made up of four elements: awareness, human issues, emotional attribution, and acceptability. Decisions to participate in the cervical cancer screening were largely influenced by the elements within ‘sexual association’, showing the psychosocial or cognitive impact of the association between sex and the cervical cancer screening procedure. Sexual association seemed to be a key influence in participation, with factors from the three main categories feeding into it. Discussion: All participants, particularly in relation to health protection, viewed the screening positively. Within the sexual association and practicality issues, there are facilitators and potential barriers. The psychosocial impact (fear, embarrassment, intrusiveness and taboos) of sex being associated with cervical screening, as well as practical issues, tends to dissuade people from participating in the screening. An explanatory model was developed to understand the factors influencing participation and non-participation and this has commonalities with the health belief model and social cognitive theory, which are typically used to explain health behaviours. This is one of the few studies investigating factors that affect the uptake of cervical cancer in the Northeast of England. The results obtained in this study are likely to have high importance to policy and practice, as they represent user-focused perspectives. Recommendations and implications for further research, policy, practice and education are provided.

Study abroad generates positive learning outcomes for students. However, experiences of learning, and processes, strategies and influences on learning during unaccompanied nursing study abroad are unclear. This hermeneutic phenomenological study therefore investigated student nurse experiences of learning during a study abroad journey in order to explore the phenomenon of learning and the processes, strategies and influences on learning throughout this journey. Twenty student nurses, from the UK and Europe, participated; two semi-structured interviews were conducted per participant (post-return and follow-up). Phenomenological hermeneutical data analysis revealed the phenomenon of learning comprised four themes: ‘experiencing a different reality’; ‘active sense-making’; ‘being with others’ and ‘being changed and transformed’. Findings identify that study abroad was experienced as the liminal space in which learning occurred. Students experienced liminality in this space and the process of learning was triggered by disjuncture. Students took responsibility for learning and undertook active sense-making activities to gain insight. Students struggled to make sense of troublesome experiences, and remained in a stuck place until resolution of troublesome-ness enabled students to cross a threshold into understanding. Threshold concepts in nursing were revealed as particularly troublesome. Learning was influenced by others; this included communitas, communities and communities of practice. Otherness also influenced student learning and position in these communities. Students experienced change and transformation as a result of the learning that had occurred. A postliminal state was attained when troublesome-ness was resolved and students had re-integrated back into their usual reality. These findings offer new practical and theoretical insight into student nurse learning during unaccompanied study abroad journeys and further development of educational policy, practice and research is recommended.

Typel diabetes mellitus can affect children of all ages and it is a life threatening life long condition which requires complex and demanding therapies in order to achieve the level of control needed to reduce long term complications. It is therefore important for healthcare professionals to understand, and be responsive to, the unique challenges that children and their parents experience as they live with this condition. The overarching aim of this qualitative study was to explore the experiences of children and their parents living with Type 1 diabetes mellitus and to develop a theoretical understanding of the meanings they ascribed. This aim remained consistent across Phases 1 and 2. However there was a shift from a broad exploration of experiences in Phase 1 to a more detailed exploration of the children's and parents' experiences around the more specific concept of normal in Phase 2. This shift in the aim between Phases 1 and 2 arose entirely from following the data. A phenomenological approach using conversational interviews was adopted. Fourteen children (aged 4-17 years) and their parents from different ethnic backgrounds and at differing lengths of time since diagnosis participated. Ten families participated in Phase One (10 children, 11 parents) and eight families in Phase Two (8 children, 11 Parents), with several participating in both phases. Data were thematically analysed over several cycles utilizing van Manen's phenomenology generating deep and meaningful insight into the experiences of children and their parents living with T1DM. The synthesis of Phase One findings identified 'normal' as being dominant in the lives of the children and their parents thus reflecting the position that diabetes makes families different and their pursuit of 'normal' more visible. 'Normal' was underpinned by four subthemes: transition, attachment, loss and meaning. Normal was a position that the children and their parents strove to attain and was the focus for the second phase of the study. The findings from Phase Two demonstrated the ways in which the everyday lives of the children and parents were shaped by the distinct and discrete understandings of the concepts of normal and different. This is best understood within the theoretical framework of the four phases of realisation which are an inextricable part of the children's and parents' lives. Further to this 'significance' and 'consequence' are crucial elements that influence the ways in which they live with diabetes. Significance and consequence are not fixed linear entities; they are dynamic, responsive and reactive. Although both children and parents experience the significance and consequence of diabetes, their individual focus and experience creates dissonance between them. The main source of tension occurs because children living with Ti DM from diagnosis onwards perceive themselves to be 'normal but different' whereas parents perceive that their child is 'different but normal'. The challenge facing health care professionals involved in the delivery of type 1 diabetes care for children is to move solely beyond the medical management and to understand the complex emotional and psychosocial demands that arise from the dissonance between the perceptions of children and their parents of Normal but Different, Different but Normal'.

This thesis explores the role of disruptive contexts and their effect upon incivility within the nursing student-lecturer relationship in higher education. Incivility has been growing exponentially, with evidence of a blame culture, polarising and disempowering both groups. Shifting the focus from attribution to contextual understanding was perceived as an empowering strategy which enabled the exploration of incivility, without apportioning blame. This was achieved through the facilitation of meaningful dialogical relationships. Utilising principles emanating from the critical theory paradigm, the Habermasian Ideal Speech Situation was applied. A triangulated approach of collaborative action research (CAR) and interpretive phenomenology provided the methodological underpinnings and method. This was delivered through a programme of six interactive workshops and individual semi-structured interviews, equally involving students and lecturers, facilitated within emancipatory reflective spaces (ERS), a term unique to the study. The promotion and facilitation of internal and external dialogues allowed for both self and group reflection. This collaborative approach enabled the development of power sharing which had to be built upon authentic relationships and not compromised by "illusion" and tokenism. Findings focused upon "looking beyond the obvious" contextual behaviour, which led to a deeper understanding of the fluid role of context in relation to incivility. This provided the conceptual underpinning for a contextual intervention framework, identifying individual, classroom and organisational approaches for minimising and coping with its devaluing effect. This research is important, as through the establishment of ERS students and lecturers developed collaborative and meaningful relationships, based upon mutual respect, authenticity and genuineness. These empowering spaces enabled them to freely explore the notion of disruptive contexts which in turn led to a deeper and conceptual understanding of the cause, effect and management of incivility. This conceptualisation and the associated interventions are both applicable to academic settings and are potentially transferable into the professional practice context.

The aim of this research was to undertake an evaluation of domiciliary physiotherapy, by assessing the cost effectiveness of a new Domiciliary Physiotherapy Service (DPS) and by analysing the process of domiciliary physiotherapy practice. The main element of the work was a randomised controlled trial of the DPS, in which an experimental group receiving domiciliary physiotherapy assessment and intervention was compared with a control group receiving conventional care. Hypotheses that domiciliary physiotherapy would improve clients' independence in activities of daily living (ADL) and health status, and reduce clients' use of other services, were tested. The null hypotheses related to ADL and health status could not be rejected, possibly because of a smaller than intended sample size, and/or the masking of real effects by sample attrition, or lack of sensitivity of the outcome measures. There was evidence to suggest that the DPS may have significantly increased, rather than decreased, the proportion of clients with at least one contact with another health or social service. The analysis of the process of domiciliary physiotherapy developed as the RCT progressed. An interpretive account of domiciliary physiotherapy practice, framed within the author's own experiential knowledge, was constructed using quantitative and qualitative data from DPS treatment records, GP referral forms, and interviews with clients, carers and experienced community-based therapists. The interpretive analysis has underpinned a new `reciprocal learning' model of domiciliary physiotherapy, which may assist practitioners working in the field. The way forward for domiciliary physiotherapy practice may be to acknowledge that measurable clinical outcomes cannot easily be determined, and that criteria for assessing the value of domiciliary physiotherapy should be based on client and carer perspectives.

Service improvements in healthcare can improve service provision; make cost efficiency savings, streamline services and reduce clinical errors. However, service improvement alone may not be adequate in improving patient outcomes and quality of care. Complexity of healthcare provision makes service improvement a challenge, and there is little evidence of whether service improvement initiatives change healthcare practice and improve patient care. To equip the nursing workforce with the skills necessary to make service improvements, Higher Educational Institutions (HEI) have developed courses that include service improvement within their pre-registration programmes. However, service improvement is a learned skill, which nurses need to practice in order to become competent in making improvements. In order to explore service improvement in nursing, hermeneutic phenomenology was used to gain an understanding of the lived experiences from student to registered nurse. A purposive sample of twenty participants were selected from an adult pre-registration nursing programme, during their third year. Data was collected using semi-structured interviews in two phases; once when the participants were student nurses and 12 months later when the same participants were registered nurses. Data analysis occurred using a van Manen (1990) approach and the hermeneutic circle to facilitate interpretation and analysis of findings. Four key themes emerged from the data; service improvement in nursing; socialisation in nursing practice; power and powerlessness and challenges in changing practice. Findings showed that the participants underwent processes of professional transformation, becoming empowered and developing resilience in making service improvements from student to registered nurse. Participants achieved this by developing positive, adaptive behaviours. A new ‘Model of Self-efficacy in Service Improvement Enablement’ is presented which explains the participant’s service improvement journey. This new model has relevance for both nurse education and practice, in seeking to improve patient care through service improvements in nursing.

The study answers the question: 'How can nurses' properly considered decisions relating to patient care be demonstrated?' Nurses in the United Kingdom have a professional requirement to demonstrate': the properly considered clinical decisions relating to patient care' (UKCC, 1994; NMC, 2002). However, their decisionmaking has been reported as complex and poorly understood, and apart from nursing records, little evidence exists to demonstrate their decisions. The development of the nurses' role as a decision-maker is traced from an origin in Nightingale's text (1860) through to the present day. This role is shaped by organisational, nursing and medical profession influences. Having established that nurses have a role as decision-makers, a conceptual framework is used to examine different explanations about the decision process, outcome, context and how decisions are made. Before undertaking fieldwork, a survey of nurses' decision-making in general medical and surgical wards was conducted. The findings were compared with the conceptual framework to generate questions and avenues for enquiry. An ethnographic study was undertaken in 1999 - 2000 in four general medical wards in two English provincial NHS Trusts with registered nurses (general). A model of decision-making was developed as a mid range theoretical explanation of how they made decisions. This involved a narrative based approach in which nurses generated an account (narrative) of knowing a patient and used this to identify needs. The patient was known in a narrative through three categories of information: nursing, management and medical. These categories were constructed through nurses' information seeking and processing using a tripartite conceptual lens. These facets correspond to different aspects of the nurse's role as a carer, care manager and medical assistant. The patient is known in three ways in a narrative, as a person to care for, an object to be managed, and as a medical case. An oral tradition surrounded its use, and nursing records were not central to decision-making. The narrative was used to make decisions and influence medical decisions. Once it was established how nurses made decisions, a method was developed to show how they could demonstrate their properly considered clinical decisions relating to patient care. This involved using the narrative based decision-making model as an analytical framework applied to nurse decision narratives. Narrative based decisionmaking offers a development of existing descriptive theoretical accounts and new explanations of some features of the decision process. This particularly includes the use of personal note sheets, the role of judgements and the cycle of communicating the narrative to nurses and its subsequent development as a process of developing an explanation of how the patient is known. Having addressed how nurses can demonstrate their properly considered clinical decisions relating to patient care, conclusions are drawn and implications explored in relation to practice, professional regulation, education and method. Recommendations include a challenge to the assumption about decision-making underpinning existing NMC guidance on recordkeeping, and the need to recognise diversity of decision-making practice across different nursing sub-groups. The narrative revealed nurses' ways of constructing knowing patients and rendering this visible. Nurses' not only have a duty, but also a need, to demonstrate decisions so that they can render visible what it is they are and do.

Previously documented evidence suggests that motherhood is potentially an important time for change in drug-using behaviour. My research interest for this longitudinal phenomenological study stemmed from practice observations where methadone-treated women struggled to prove their trustworthiness as mothers. They consistently reported frustration in the face of continued professional suspicion of their identity as drugusers. The essence of the phenomenon is therefore described as an existential tension experienced by breastfeeding mothers in methadone maintenance treatment during the first 12 weeks of motherhood. The aim of this thesis is to reveal the previously hidden inter-subjective and social realms of their lived worlds.

Caesarean birth accounts for a quarter of all births in England and is the most commonly performed operation. Despite this, little is known of how individual women experience planned Caesarean birth. Reviews of the literature reveal that rising rates of Caesarean birth are preceived to be problematic by women ,clinicians and policy makers but women's experiences are either absent from this debate or perceived as universally realised. This qualitative study involved listening to the stories of eight women to reveal how planned Carsarean birth was experienced, understood and constructed.