Thesis (Ph. D.)--University of Washington, 2000. / Vita. Includes bibliographical references (p. 271-291).

Thesis (MHSc--Health Science) -- AUT University, 2009. / Includes bibliographical references. Also held in print (viii, 217 leaves ; 30 cm.) in the Archive at the City Campus (T 618.20233 FER)

Scholars and midwives agree that women’s autonomy over decisions related to birth is not being respected in a country where there is mainly one birth setting and one type of provider, in particular, when this setting and provider are often link to the use of unnecessary and excessive medical interventions. This is the case of Puerto Rico. I argue that midwifery could be an answer to this problem. Midwifery in Puerto Rico is not yet regulated, but I claim that in order to promote Puerto Rican women’s autonomy, midwifery regulation has to be well thought. This thesis includes an analysis of a bill proposed in Puerto Rico that pretended to regulate midwifery. Submissions presented to the legislature are also analyzed and criticized in this thesis. Some recommendations are provided on how Puerto Rico can enact a sensible scheme of midwifery regulation that would enhance midwives autonomy and therefore women’s autonomy.

Scholars and midwives agree that women’s autonomy over decisions related to birth is not being respected in a country where there is mainly one birth setting and one type of provider, in particular, when this setting and provider are often link to the use of unnecessary and excessive medical interventions. This is the case of Puerto Rico. I argue that midwifery could be an answer to this problem. Midwifery in Puerto Rico is not yet regulated, but I claim that in order to promote Puerto Rican women’s autonomy, midwifery regulation has to be well thought. This thesis includes an analysis of a bill proposed in Puerto Rico that pretended to regulate midwifery. Submissions presented to the legislature are also analyzed and criticized in this thesis. Some recommendations are provided on how Puerto Rico can enact a sensible scheme of midwifery regulation that would enhance midwives autonomy and therefore women’s autonomy.

The history of 19th century nursing reforms has focussed almost entirely on the activities and lives of nurse leaders, to the exclusion of the ordinary nurses. The lives of such nurses at one London hospital, St George's, have been investigated using a methodology based on prosopographical techniques. It was found that by the end of the century, far from becoming the exclusive preserve of middle class women, as some historians have argued, the Nursing Department at this particular hospital had become a melting pot of social classes. Appointment and promotion depended on ability rather than social position, and many women at the Hospital viewed nursing as a career, rather than a stop-gap before marriage. Evidence has also been accumulated which challenges the image of late 19th century nurses as being meek and docile women. The nurses at St George's were prepared to challenge the authorities to gain recognition for their various causes. Between 1850 and 1900, the Hospital Managers focussed increasingly on improving conditions of employment (including wages, accommodation and holidays) as a means of achieving stability within the Nursing Department, and of attracting a 'better quality' of woman. Nursing training was introduced during the fifty years of this study, although this was a slow process compared to its introduction at other hospitals. Financial considerations appeared to play a greater role in the development of probationer schemes, than a desire to improve the quality of nursing within the Hospital. The study of a group of Victorian nurses, such as this, provides insight into the development of nursing during the period, and reveals details which contradict the writings of nurse reformers. It also aids in the understanding of wider issues, including the changing role of women in Victorian society, and in particular their increasing participation in the labour market.

Over the past 20 years reflective practice has maintained a firm presence in health professional education and practice. The notion that reflection enhances learning and professional practice is widely reported in the literature. With the continuing changes in health care, it is vital that midwives, like other professionals, develop the skills to critically evaluate care provision. Reflection is considered to be deliberate, complex processes for enhancing professional development, linking theory and practice, learning from experience, and for .promoting critical thinking and lifelong learning skills. Drawing on the work of leading theorists in the field, theoretical concepts relating to professional knowledge, learning, professionalisation and reflection were utilised to inform the empirical study. Reflective journal writing is one learning strategy used in professional education to develop reflective practice. Extensive review of literature about its use revealed limited investigation specifically relating to midwifery. The aim of this study was, therefore, to establish the perceived influence of reflective journal writing in pre registration midwifery students' experiential learning in a singularity. An ethnomethodological approach was adopted as it entailed investigating individuals interacting in an ordinary setting, and in a holistic way. Phenomenological ideas about conducting research supported the methods used to construct and give meaning to participants' actions within this social context. Multiple research methods were used to ascertain students', midwives' and lecturers' perception of how critical reflection was facilitated. Qualitative data were gathered through, for example, structured group discussions, semi-structured interviews, the analysis of journal entries and secondary data sources. A purposive sample of students (n 105), midwives (n 25) and lecturers (n 12) were chosen on the basis of convenience and accessibility within the research timeframe. The study revealed that both midwives and students had a superficial understanding of reflection. A key finding was that although students experienced some difficulty with journal writing they identified many benefits, particularly in relation to acquiring midwifery knowledge. Both mentors and lecturers played a pivotal role in students' development as reflective practitioners. However, the research identified some inconsistency in the approach to facilitating reflective practice and concluded that the quality of students' reflective writing would improve with better preparation and ongoing support. Having engaged in reflective journal writing during the course, newly qualified midwives viewed reflection as a necessary part of their day-to-day practice, assisting them with structured, thinking about practice issues. Overall, the implications for midwifery practice raised by the findings relate to how a culture of reflective practice could be better promoted, the conditions required for students to utilise reflective journal writing effectively, and the importance of consistency in approach when implementing this learning strategy.

The UK has one of the highest young pregnancy rates in the developed world (Unicef, 2001). An association between socio-economic environment and young pregnancy is evident, with deprived areas having higher under-18 conception rates and lower proportions of abortions than affluent areas (e.g. Uren, Sheers & Dattani; 2007). Presently, the processes underlying this association are unclear (e.g. Lee, Clements, Ingham, & Stone, 2004). The forthcoming studies therefore have set out to explore the mechanisms and processes through which the socio-economic environment influences young people's sexual and reproductive decisions and behaviours. A theoretical framework drawn from critical psychology, social psychology and epidemiology was used to provide a detailed exploration of this association. The role of cultural and social factors as possible processes by which socio-economic environment influences young people's sexual, reproductive and pregnancy decisions were explored using social representations theory framework (e.g. Moscovici, 2000; 1976) and cultural and behavioural explanations of social inequalities (such as suggested by Townsend & Davidson, 1983). Young mothers (N=16) and fathers (N=5) from a mix of socioeconomic environments were interviewed about their experiences. These data were used to design future studies. The first of these, addressed social acceptance of young pregnancy in areas characterised by different levels of deprivation (N=570), while the second used questionnaires (N=49) and focus groups (N= 10) to explore the antenatal ,. and postnatal needs of young parents as well as the reasons for their low attendance. These studies suggest that the image of pregnancy and parenthood offered to young people through the process of intra-cultural communication differ from their actual experiences - this discrepancy between the imaged and real picture for young parents' impacts upon their emotional well-being and future plans. Social inequalities influence young pregnancy outcomes through social representations. Within each economic subgroup (more deprived and more affluent areas and families) different social representations produce varying values and beliefs concerning sexual and reproductive behaviour, gender roles, role models and social acceptance of young pregnancy and abortion. Several issues warrant further exploration - these include socio-economic variations in contraceptive use and reasons for non-use, the influence of gender roles, the need for ward-level comparisons and the influence of culture and subcultures on sexual, reproductive and pregnancy decisions.

An Examination of the Emotional Labour of Nurses Working in Prison Mann (2004: 208) identifies three components of emotional labour: 'The faking of emotion that is not felt and/or the hiding of emotion that is felt, and the performance of emotion management in order to meet expectations within a work environment.'Nurses working in prison in England and Wales have a dual role; that of both carer and custodian. This thesis examines the emotional labour of nurses working in adult prisons who undertake a dual role in both caring and custody. A qualitative, reflexive methodology was adopted with a postmodern philosophical foundation. Phase one of the study involved semi-structured interviews with nine qualified nurses from three adult prisons: two male establishments and one female. In phase two of the study, two of these nine nurses entered into a supervisory relationship with the researcher. Monthly clinical supervision sessions were held with both nurses over six months. Findings from this study suggest that the nurse working in prison experiences emotional labour as a consequence of four key relationships: the relationship with the prisoner patient, the relationship with officer colleagues, and the relationship with the Institution; the fourth relationship centres on the contradictory discourses the nurse engages with internally, and is referred to as the 'intra-nurse' relationship. This relationship involves on-going internal dialogue between the two selves of the nurse: the professional self and the emotional 'feeling' self. In order to manage the emotion work inherent in prison work, it is suggested that the development of emotional intelligence through clinical supervision and reflective practice is of significant benefit to both health care and discipline staff. This is the background image for an unknown creator of an OCR page with image plus hidden text.

The aim of this study was to illuminate the experience of early mothering for a small group of first-time mothers from the Southof England in 2001. Central to this were the detailed descriptions, as recounted by the women, of the way in which they gradually adapted to being mothers. In this phenomenological inquiry seven women shared their stories with me. The interview took place at a time and place of the women's choosing and they were asked to describe,in as much detail as possible, the way in which they had experienced "becoming a munf'. Each womantook a unique and circuitous journey to mothering and their narratives were rich and evocative, revealing the complexity of the transformative process. The datawere analysed using a descriptive phenomenological approach, which revealed seven constituents contained within a general structure. Although the women interviewed provided notably contrasting descriptions,underlying and uniting their individual experiences was the general structure. This can be summarised as, "Becoming a mother for the first time introduced some fundamental changes into the woman's manner of being in the world. Essentially,this concerned the development of a new becoming-a-mother-change-of-body subjectivity in which the woman was required to re-order her way of being in all its existential dimensions. The new mother sought to integrate and authenticate this challenging life event within her biography-she manifested both an openness to the beloved child and a resistance to the truncation of her existential possibilities." This is not to say that the women all experienced the phenomenon in the sameway, instead there were particular essential constituents through which each woman negotiated her transforming journey into motherhood. Some women assimilated these changes to their embodied self with ease, others struggled and resisted, feeling assailed and overwhelmed. The seven constituents are: " Welcoming the intimate stranger " Anxious loving " The baby fills her vision " Acceptance:from crisis to comprehension " Exhaustion,recovery and the physical body " Relationships:re-evaluation and conflict " Isolation, ambivalenceandtears The data also challenged mainstream understanding of postnatal depression as a discreet, diagnosable illness. Becominga mother is a transition that compels women to make radical re-adjustments to every aspect of their manner of 'being-in-the-world'. It would be extraordinary if this did not cause significant levels of distress,dis-equilibrium and a sense of chaotic disorganisation.I propose that distress in early mothering is understood as a normal reaction to a significant life-changing event. Implications for clinical practice and further research are also discussed.

This thesis presents a body of publications, in the area of critical care nursing, for consideration for the award of Doctor of Philosophy by Publication. The thesis is presented in three chapters: Introduction; Body of Work; and Research, Knowledge, Evidence and Practice. In the first chapter the emergence of evidence-based practice is described, in general. Initially, an overview of the origins and trends of nursing research methodology is provided; the purpose of which is to set in context the body of work. Utilising a narrative approach (Boje, 2001; McCance et aL, 2001; Sandelowski, 199 1; Vezeau, 1994) as a 'personal journal of discovery' I then reflexively describe my own development as a nurse researcher practitioner, drawing on my own publications to illustrate my progress, the development of my thinking, my research practice and the development of my understanding of pragmatice pistemology. The second chapter is comprised of my publications relevant to critical care nursing. Spanning a period of eleven years, they represent my contribution to critical care nursing knowledge. In the concluding chapter I have summarised initially my own contribution to critical care nursing knowledge, before moving on to a more detailed critique of evidence-based practice. Finally I have made recommendations for the way forward. In addition to presenting my body of work, the aim of this PhD is to challenget he current concept of evidence-based practice, arguing that its definition is too narrow to encompass the rage of different types of knowledge that nurses use when caring for critically ill patients. I have utilised my own publications, to demonstrate how a variety of approaches are necessary to provide the best evidence for developing practice. I have positioned my argument within a theoretical understanding of pragmatic epistemology. In this way, I am working towards the development of a science of practice. Simultaneously I am also, to some extent, challenging conventional concepts of what constitutes doctoral level knowledge and how a PhD looks. My conclusion is that critical care nursing knowledge is drawn from many sources, and should be applied in an integrated way that enables practitioners to make a positive difference to the life of patients.Knowledge that is not or cannot be applied to practice is therefore of no value. The valuing of practice knowledge brings with it the requirement that all forms of knowledge (and their relevant methodologies) are considered as equal,in terms of their potential to impact on practice and that nothing should be rejected on paradigmatic grounds. In contemporary healthcare evidence is hierarchically valued and this raises many questions of equity. Where the value of knowledge becomes unequal is when its application to practice is limited. The corollary of a pragmatice pistemology is that it requires a pragmatic process to make it work. For me, at this point in time, the best available is practice development. In summary,this thesis represents a construction of work that makes an original contribution to knowledge. The product of my thesis is a theory of pragmatic epistemology as the basis for a science of practice.