This study aimed to evaluate stroke rehabilitation services including the quality of services and the opinions of multiple stakeholders involved in stroke rehabilitation. Several methodologies were employed including a literature review, content analysis of national documents, case note audit and questionnaires of patients, staff and commissioners. The content analysis identified 214 separate recommendations from 15 documents. Of these 21 were relevant to every patient receiving stroke rehabilitation; 13 related to the overall service provision and 8 related to specific aspects of patient care. These recommendations were converted to standards and used to audit the 10 stroke rehabilitation services in Greater Manchester using 100 individual patient records. 146 patients completed a satisfaction questionnaire, 46 staff and 6 commissioners completed questionnaires. Results demonstrated variable compliance to national recommendations with primary stroke centres showing greater adherence than district stroke centres, indicating a two-tier service. All services offered a weekly multidisciplinary team meeting, 93% of patients spent most of their time in hospital on a specialist stroke ward and 96% commenced rehabilitation as soon as they were medically stable. However, only 22% of patients received 45 minutes of therapy per day and 4% received a discharge plan when leaving hospital. Staffing levels did not impact on adherence to national recommendations, however the most long-standing and prominent recommendations achieved greatest compliance. Patients felt that they were treated with dignity, with older patients being more satisfied with stroke rehabilitation services than younger patients. However, patients did not feel that they received enough therapy or information relating to their goals within rehabilitation. Staff felt patients should receive more therapy than they currently do; patients should receive more than 3 hours a day despite currently receiving less than 60 minutes a day. The amount of therapy offered varied across disciplines with speech and language therapists providing less therapy than occupational therapists, physiotherapists and nursing staff. Staff felt the primary factor limiting the amount of therapy was staffing levels. Commissioners' primary priority was to improve the outcomes for stroke patients, however different monitoring mechanisms between localities leads to the potential for different priorities and accountability. This study is the first to systematically compile and evaluate national recommendations within stroke rehabilitation services and to include commissioners in the evaluation of stakeholders’ opinions.

Objectives: The primary aim of this UK-based study was to identify core clinical competencies (skills, knowledge, attitudes, and behaviours) for primary-care-based extended-scope physiotherapists (ESPs) working in the field of adult musculoskeletal (MSK) medicine. Although the musculoskeletal (MSK) ESP role in the UK has been in existence for over 10 years, there is no competency and curriculum framework supporting these posts. This study used a consensus-building methodology with a multidisciplinary panel of MSK experts to identify core clinical competencies for MSK ESP practice. Methods: Purposive sampling was used to recruit MSK ESPs and MSK medical experts from six specialist fields within medicine: rheumatology, neurology, neurosurgery, general practice, orthopaedic surgery, and rehabilitation medicine. Seventy-two experts volunteered to take part in a three-round online Delphi survey and fifty-six experts completed all three rounds. Qualitative data from the first and second questionnaire rounds were analysed using content analysis, and descriptive statistics facilitated the presentation of quantitative data. Principal findings: The expert Delphi panellists identified 104 core clinical competencies for primary-care-based MSK ESP practice and they reached a consensus view on 85 competency items. Importance and Relevance: This is the first study to have identified core clinical competencies for primary-care-based MSK ESPs. Although further work is required to validate the results of this Delphi survey, they represent a contribution to knowledge in the field of MSK ESP practice and they should assist the professional body and the health care regulator with their development of a nationally agreed competency and curriculum framework for MSK ESP practice.

Introduction: Over the last decade there has been a significant increase in the use of computerised clinical decision support systems (CCDSS) in health care. While significant research has been carried out to demonstrate the impact of CCDSS, the role of CCDSSs in Emergency Departments (EDs) remains under-investigated. The aim of this study was to investigate if the introduction of a CCDSS at ED triage, improved the quality and safety of decisions at triage and improved overall departmental safety. Methods: This study adopted an interrupted time series design, with 8 time points. A random sample of triage records (n=400) from the year before the introduction of eTriage (four time points) were compared to the same number of records from the year after its introduction. Data was extracted from ED clinical records to establish the accuracy of triage prioritisation as an indicator of safety and the management of pain as an indicator of quality. A smaller subset of cases (n=44) over the same time period were analysed to assess any differences in the clinical management of patients presenting with neutropenic sepsis, a further indicator of safety. Logistic regression analysis was undertaken to expose the underlying decision-making trend over the whole study period. Results: This study demonstrates a statistically significant improvement in triage prioritisation (p<0.001), pain scoring (p<0.001) and pain management (p<0.001). Logistic regression demonstrated improvements in decision-making above what have been expected if eTriage had not been introduced. For patients presenting with neutropenic sepsis there was no statistically significant difference in their clinical management. Conclusion: This study clearly demonstrated the positive impact that a CCDSS can have on the quality and safety for ED patients and provides a unique contribution of the current ED CCDSS knowledge base. The ever-increasing demand for emergency care and the difficulties in recruiting an experienced workforce is a fertile environment for clinicians to harness the potential that technological solutions can offer.

Studies of childhood bereavement suggest that communication is a crucial issue for adults and for children (Silverman and Worden, 1993). Closed communication seems to be a ‘natural’ adult response and this seems to be shared by some professionals. This study was designed to explore aspects of communication between adults and children experiencing loss or impending loss. The study consisted of five investigations: 1) An analysis of narratives obtained in interviews with 4 adults bereaved in childhood; 2) An exploration of 8 narratives illustrating the theme of children’s grief in literature; 3) An exploration of communication strategies used by 6 counsellors working with bereaved children; 4) An exploration of 6 counsellors’ communication strategies obtained by interviews with counsellors and volunteers and 5)An evaluation of a support programme using qualitative data from brief interviews with 24 participating children, attending 2 distinct, age appropriate, groups. A semiotic analysis of texts culled from the investigations was carried out. In Investigations 1 and 2, it was established that silence functioned as a sign whilst, unsurprisingly, the investigations in which counsellors’ communication was analysed (3 and 4) showed that empathy and dialogue were central. The specific question addressed in the first investigation was whether closed communication had operated in the lives of bereaved children who are now adults and, in the second, whether this is found across generations and cultures. The findings in both cases gave an affirmative answer. The evaluation of group support for 24 children suggested that the programme had been helpful in resolving shorter term effects of loss and lends some support to the notion of ‘Continuing Bonds’. The research question formulated for the study was: What psychological tools, including signs, operate in adult-child communication in this context. The main finding was that both open and closed styles of communication are employed.

The aim of the study was to discover the most suitable methods of psychologically preparing patients for modern day surgery and to formulate a pre-operative nursing plan which embraces such methods. Contemporary evidence suggests the level of information provided, individual coping style, anxiety and social cognitions may strongly influence the psychological status of patients undergoing surgery. However, the most crucial aspect within day surgery may concern the degree to which the level of information provided meets with individual requirements i.e. information matched with maximum (vigilant coper) and minimum (avoidant coper) levels of requirement. A convenience sample of 120 patients undergoing intermediate, non-life threatening, gynaecological laparoscopic day surgery were contacted prior to admission and randomly assigned into two groups. Group I received an extended information booklet and Group II a simple information booklet. All participants received a questionnaire pack pre-operatively which was utilised to determine coping style, anxiety, health locus of control and self-efficacy. Initially, the nurses rated participants in receipt of the extended information as less anxious, irrespective of coping style (F (1, 47) = 4.257, p = 0.45). However, irrespective of the information booklet received, participants with a vigilant coping style encountered greater external health locus of control (F (1, 47) = 4.249, p = 0.045). Again, irrespective of the information booklet received, participants with a vigilant coping style also experienced lower self-efficacy (F (1, 47) = 6.173, p = 0.017). As participants in receipt of the extended information booklet were observed to be less anxious, the ability of the booklet to alleviate anxiety is discussed. Additionally, regardless of information received, vigilant coping behaviour was associated with diminished health locus of control and lower self-efficacy. Such sub-optimal appraisals are equally explored. An innovative plan is proposed providing explicit psycho-educational guidance for intervention throughout modern elective day surgery. Incorporation of this strategy into nursing practice is outlined and techniques for implementation recommended.

This action research study investigated the feasibility of building evaluation capacity into the design process of Greater Manchester Fire and Rescue Service’s (GMFRS) community initiatives. GMFRS runs over 400 community initiatives every year and an appropriate evaluation framework is needed to provide evidence of their impact and effectiveness. Information that previous evaluation processes had failed to provide. The feasibility of establishing an evaluation framework for use by non-specialists users was explored, the development of a new evaluation system for GMFRS was examined critically, and the processes and challenges involved in embedding evaluation within a large public sector emergency service investigated. Mixed research methods -- document analyses, qualitative interviews, observations and focus groups -- were used in the three action research cycles conducted between April 2008 and April 2010. In cycle one, existing evaluation materials and key characteristics of the initiatives were assessed. GMFRS’s community initiatives were found to lack direction, and the existing evaluation tool lacked the detail required for use by personnel with no previous evaluation experience. Hence, new evaluation materials were developed and, in the second cycle, their use was observed, and interviews conducted to ascertain the barriers to evaluation practices. Lack of resources, organisational guidance, and support with evaluation activities were identified as barriers. In the third cycle focus groups were used to gain feedback on the usability of the new evaluation material and processes. The principal conclusions of the research are that there were no theoretical models and/or guidance to assist Emergency Services to develop internal evaluation capacity. Insufficient attention has been paid to organisational support processes to nurture individuals’ evaluation skills and abilities, and to assist complex organisations utilise evaluations. For evaluation to become an embedded and systematic activity, it has to be supported by a project management methodology that underpins evaluation processes.

There is an investment of hand-pump technology to improve provision of safe drinking-water for the stakeholder end-users in rural sub-Saharan regions of Africa, yet there are challenges to maintain the assets. In rural drinking-water projects, end-users also assume the responsibility of hand-pump maintenance after projects are handed over to them by project sponsors. This study uses a realist philosophy to analyse the issues that hinder or facilitate effective end-user participation in a successful maintenance of drinking-water projects in Nkhoma and Bvumbwe, Lilongwe and Thyolo Districts of Malawi respectively. Data collection was done by employing secondary data (literature review) and primary data collection using documents, observation, and interviews to establish factors facilitating or inhibiting hand-pump maintenance. Interviews which were the main data collection instrument, recruited 12 Convergence Interviews (CI), followed by 39 Individual Case Interviews (ICIs) and two sets of Focus Groups (FGs) in operational and non-functional hand-pumps. CI processes developed categories related to hand-pump maintenance factors and associated challenges. The CI developed maintenance categories were further cross checked in ICIs that used semi-structured interviews and finally confirmed in FGs, documentary and observational analysis. Convergence Interviews data was analysed using a matrix while ICIs were analysed using likert-type ranking scales to identify the most occurring hand-pump maintenance factors. Focus Groups, observations and documents used content analysis to analyse the hand-pump maintenance factors. Results show that end-users maintain small- medium hand-pumps faults effectively if they pay a contribution towards maintenance costs and if local political structures are trained to repair the hand-pumps. Moreover, the study identifies lack of sponsor supports as the main factor leading to failure in the management of major faults and hand-pump rehabilitation, as this is beyond local capacity technically as well as economically. Hence, the study introduces a business approach to improving hand-pump maintenance by recommending some minimum standards on the demand-side (end-user level) as well as the supply-side (project sponsor and policy levels).

The growing recognition amongst local authorities of the potential of asset management to improve property management practice has led to its increased adoption. The growing trend has been supported by the development of asset management frameworks. However, evidence indicates that local authorities are failing to achieve the full benefits from their asset management implementation. The factors contributing to some of the property management problems such as reactive management, lack of leadership support, ineffective corporate landlord approach, remain. The available frameworks are incapable of mitigating the identified problems by failing to provide understanding of local authority differences. Therefore, this research aimed to develop an adaptable and flexible operational property asset management framework for local authorities in England and Scotland. The strategic management theory, review of existing literature findings and evaluation of available asset management frameworks especially the Total Asset Management Process model helped to identify, define and establish the causal logic of the asset management concepts underpinning the developed conceptual framework. Face to face semi-structured interviews followed by large scale questionnaire surveys were used to gather primary data. The key research findings are that the following are the key factors limiting asset management practice improvements in local authorities: ineffective leadership support, asset management capabilities and corporate landlord approach; inadequate asset management information systems and performance management arrangements. Principal components factor analysis was utilised to help establish underlying factors that account for flexible and adaptable asset management framework. The findings suggest that asset management processes associated with an adaptable and flexible asset management framework include a board level cross functional asset management structure; strong leadership support for both direct and indirect property; an enabling environment; an effective corporate landlord approach; an effective performance management arrangement; and availability of an appropriate management information system. The framework has been validated to be robust and can be utilised and flexibly adapted by different local authorities and provides the basis for improving the process and outcome of asset management practice.

A functionally connected urban tree infrastructure (UTI) contributes to ecosystem function, resilience, and the provision of Ecosystem Services (ES). Variation in tree height is an important attribute influencing movement of passerines, habitat quality and landscape patterns. UTI provided ES are particularly beneficial in the most deprived areas of a city. Presented in this thesis is an exploration into the social-ecological shape of a UTI using a holistic, multi-scale and dimensional, landscape approach. The potential landscape connectivity of a UTI in the City of Salford, UK was quantified and compared using the integral index of connectivity (IIC) across vertically stratified canopies existing in 2005, 2009, and 2013. System resilience was assessed through landscape graph network analysis and by the identification of canopies critical in maintaining connectivity (dIIC). The index of multiple deprivation (IMD) was related to UTI landscape composition and configuration through a series of statistical tests. The connectivity of Salford’s vertically stratified UTI was low (IIC = <0.000001 – 0.0045), besides this the temporal change in connectivity was complex with no discernible overall pattern. The rate of connectivity increase decreased after a 90-120m gap-crossing threshold. The resilience of Salford’s UTI relies on the connectivity of canopies within 4 to 5 sub-connected regions, depending on passerine perception, increasing to 10 -16 smaller regions for canopies above 17.1m. The resilience and stability of these sub-connected regions were often reliant on a central canopy patch. UTI composition is related negatively with deprivation, UTI configuration is related positively, while structural diversity of canopy heights revealed no correlation with deprivation. The research in this thesis contributes to the debates on how to best manage the UTI for both people and nature. The findings of this thesis have a number of important implications for future urban landscape management, especially as previously unknown landscape patterns have been identified.

Social-ecological systems describe interactions between humans and nature. The ecosystem approach provides a holistic system to manage and understand these interactions, and to maintain and enhance ecosystem services - the benefits nature provides to humans. While much theoretical discourse posits various approaches to the ecosystem approach and ecosystem services, there exists a lack of practical applications examining these approaches, especially in urban and peri-urban environments. The current research used a case study to examine the efficacy of integrating environmental management and ecosystem services within an urban greenspace social-ecological system. Initially, the most pertinent ecosystem services and management options were established. This was achieved through expert opinion, a rapid assessment, and a literature search which enabled the identification of a preferred management approach. This resulted in conservation grazing cattle over a 5 hectare salt marsh, typical of the Upper Mersey Estuary in the UK and situated within an urban area. The effects of cattle grazing on four relevant ecosystem services: (i) wild species diversity, (ii) environmental settings, (iii) carbon storage, and (iv) immobilisation of pollutants, were evaluated over two years. The aim of the evaluation was to examine how the grazing intervention affected ecosystem services. Both quantitative and qualitative measures - reflecting the interdisciplinarity of the ecosystem services concept - were used in the evaluation. For the ecosystem services examined, the results add significant knowledge to the current discourse, and are used to inform new avenues for research. There was an increase in the cultural services (wild species diversity and environmental settings), regulatory services of carbon storage showed no change while differences in the immobilisation of pollutants observed were explained by local variation at the site. These findings show that by integrating ecosystem services and environmental management, larger scale benefits to humans from management options can be recognised and planned for in future natural spaces management, thereby increasing the positive rewards nature provides in abundance.