There is widespread concern over the high levels of reported work-related stress, job dissatisfaction and psychological distress associated with teaching and the effects of stress on teacher's sense of well-being and their willingness to stay in the profession (Borg, 1990; MSLAT, 1996; Troman, 1998; Schonfeld, 1990; Wilson, 2002). Much of the traditional research on teacher stress has been carried out by external 'experts' using quantitative survey type approaches to analyze occupational stress levels resulting in restrictive data analysis unrepresentative of the true picture of stress in the teaching profession. Researchers have advocated a more holistic approach incorporating mixed methods combining both qualitative and quantitative methods in order to gain subjective teacher reports of stress and coping mechanisms resulting in a fuller picture on teacher stress with future recommendations grounded in research. Recently, the reflective practice movement in healthcare (eg:-Boswell, 2007) has suggested using a more integrative approach to advance practitioner knowledge and empower them to improve practice through reflection to create an understanding ofthe issues within a local context. My research was particularly interested in the issues relating to teacher stress including the way teacher stress was being measured and the effectiveness of qualitative over quantitative methods, the inclusion and exclusion practices of disruptive students and the use of practitioner research to encourage teacher collaboration as a way of dealing with teacher stress. Practitioner-Research methodology has been successfully adopted in Nursing and Health-Care and has recently been used in Education with mixed findings some successfully advocating p-r while other research was hampered by bureaucracy and top-down managerial agendas. In relation to this a single UK Secondary school was researched as a case study by the investigator who taught Sixth formers A'level Psychology at the school. The research was conducted in phases using a qualitative multimethod approach incorporating triangulation to include staff, students and researcher reflections about practice in order to encourage staff collaboration, empowerment and meta-cognition. A reflexive stance was thus adopted to underpin the research methodology. Semi-structured qualitative interviews were conducted on 20 teachers (varying levels, ages and mixed gender) to assess the proposed research objectives. Classroom observations and student interviews were carried out for a year 10 class to complete the data collection. The findings revealed how students felt caught up in a selffulfilling prophecy with teachers seeing them negatively, leading to a spiral of failure and lack of motivation and the teacher interviews with both newly qualified and experienced teachers, uncovered how different coping strategies were used to deal with disruption, classroom and task management in general. The most important findings came from middle managers who claimed there was poor communication between senior tiers and lower teaching tiers with a strong sense of bureaucracy ruling their decisions. In order to bridge this gap, the practice development phase of the research tried to establish collaborative meetings in order to encourage teachers from all levels to self-reflect, deal with problematic issues and action research solutions of teaching practices. The Senior Management Team (SMT, including the Head) did not encourage staff or the researcher to proceed further with the final phase and the research was abruptly halted. Despite this, I believe that practitioner-research is a viable methodology in education research as it gives 'ownership of knowledge' to the practitioner using a self-reflexive stance to increasing their evidence-based practice resulting in a growth in meta-cognition to make improvements in practice. I feel, we need to increase insider research and use Action Research spirals and collegial collaboration as a wayforward.

Background: Breastfeeding is recognised as the optimal feeding method, conferring short and long term benefits to infants and their mothers. In the UK some women do not initiate breastfeeding. Many commence formula milk feeding at birth or after a brief period of breastfeeding. Often women have decided how to feed their infants before conception or even during adolescence, prior to when infant feeding education has traditionally been provided. Negative attitudes to breastfeeding amongst some social groups, and lack of familiarity with the practice appear to contributing factors. This research has explored infant feeding awareness of children in primary schools as a first step towards informing appropriate health education interventions. Methods: Fifty six children aged 5/6, 7/8 and 10/11 years were recruited to the study from 3 schools in rural and urban areas of Southern England. Children were shown a series of drawings, and read a story about a hungry baby. They were asked to finish the story, showing how they thought the baby was fed, using the ‘draw, write and tell’ method, developed as an adaptation of ‘draw and write’. The children produced one or more pictures, often with text, and were offered the opportunity to talk about their work; the data were united in a ‘commentary’. Codes emerged, which were combined into categories. Mapping and charting techniques were used to identify five key areas for discussion. Results: The development, and flexibility, in children’s ideas regarding infant feeding was noted. Whilst breastfeeding was identified by some children, breastfeeding terminology and imagery were problematic for many. The prevalence of feeding bottles and references to formula milk were striking, with children identifying these as equivalent to breastfeeding. Solid foods were frequently referred to by children, and seemed to be identified with formula milk feeding rather than breastfeeding. Conclusions: For the first time this study identified primary school children’s awareness of different feeding methods and the inter-relationships between these methods. It appeared difficult for children to view breastfeeding as normal, perhaps because it is rarely seen or discussed, and formula milk feeding is so prevalent. The children were interested in the subject and it is anticipated that infant feeding education with these age groups would be beneficial. Introducing children to breastfeeding needs to be achieved with care and sensitivity, using language and imagery with which they are confident. In addition, the efficacy of ‘draw, write and tell’ and the challenges of using this method are discussed.

Background- The recent modernisation of the United Kingdom (UK) National Health Service (NHS) has included a number of sizeable reforms that have emphasised partnership relationships between patients and professionals, and the importance of individuals taking a more active role in their care. Many of these changes have been specifically geared towards patients with chronic health conditions, who are recognised as imposing the largest strain on health services worldwide. This modernisation has occurred in parallel with a huge increase in the number of people within the UK who are turning to the internet for health information in order to become more informed about their health and treatment regimes. Despite this increase in the prevalence of online health information (OHI) seeking, relatively little is known about how people seek OHI and the impact it has on their lives and relationships with others. Overall Study Aim- This study sought to understand the OHI seeking experience of individuals with chronic health conditions by using an innovative mixed-methods approach to collect a breadth and depth of relevant information on the topic. Design – One hundred participants were recruited from local support groups for various chronic health conditions. The participants in the first stage of the study completed one of two questionnaires, depending on whether or not they had sought OHI in the past. The design and focus of stage two of the study was guided by the findings from stage one, and subsequently focused on the experiences of older adults with chronic health conditions seeking OHI. A descriptive phenomenological approach was adopted in order to provide rich descriptions of patients’ experiences. Six participants were purposefully selected from a parallel sample to the stage one respondents. Findings- The results from stage one provided a breadth of information about the OHI seeking experience for people with chronic health conditions. Findings suggested that health professionals were still the most important source of health information for users and non-users of OHI; that patients had an awareness of the inconsistencies in terms of OHI quality; and identified the perceived ease with which useful and relevant OHI was located. A further key finding was that high age, low education levels and low internet usage not only acted as barriers to OHI seeking for participants, but also had a negative impact on participants’ perceptions of the positive outcomes of OHI seeking, such as confidence in decision-making or engaging in discussions with health professionals. Moreover, some non-users demonstrated that they felt they were “too old” to engage in OHI seeking. Stage two findings demonstrated 5 key themes: patients taking responsibility for their health; their expectations of OHI; explicit confidence in their own ability to discern OHI and concern for others to do the same; the selective nature of OHI sharing between patients, and patients and health professionals; and the reinforcement of social sharing networks where positive and useful OHI is shared freely. Conclusion- Although older adults within this sample were less likely to engage in, and perceive the positive outcomes of OHI seeking than their younger counterparts, some older adults were successfully engaging in the OHI seeking experience, and perceiving the constructive effects of this experience such as empowerment. Furthermore both stages of the research demonstrated the valuable role health professionals play in supporting patients seeking OHI. Implication- This study demonstrates a need for health professionals to actively support patients in seeking OHI. In doing so, this could reinforce OHI seeking behaviour, and assist patients in effectively searching for and appraising OHI.

Background. There is a wealth of literature demonstrating that women are critical of their care on the postnatal ward, but little information as to why. This ethnographic study therefore explored the context of care on the postnatal ward and women's views of that care. Method. The study was undertaken in one Acute NHS maternity unit in the South of England. Non-participant observation was undertaken to explore activities and interactions between the care-givers and women within the ward environment. This was followed by in-depth interviews with twelve women between two and five weeks postnatally about that experience. Findings. Analysis revealed the impact of the hierarchical structure within the organisation which pervaded through and rendered the care of women marginalised. Midwives maintained efficiency in their interaction with the women and their main focus was on 'processing' the women through the ward. Care was articulated through the procedural language of 'checks' and 'work' illustrating an ethos of 'task-based' contacts between midwives and women. The midwives felt ambivalent and physically withdrew from the women upon completion of set 'tasks'. comprising primarily physical care. Women, as passive recipients, were not able to make themselves heard and therefore individual care needs were not always met. This 'functional relationship', valued and supported by the organisation, offered an 'unconnected presence' to the women. Women sought a 'connected presence' from the midwife in recognition of their needs. In the absence of emotional or physical support, some women sought support from the other women or 'opted out' by transferring home earlier that originally intended to receive support from their immediate family and their community midwife. Conclusions. A formal definition of 'care' which encompasses physical and emotional aspects appears lacking. Midwives must reconsider how individualised care, desired by the women, can best be provided.

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.

The overall aim of this study was to explore the reciprocal impact of health policy on public health nursing and public health nursing on policy. This study uses a new approach to considering public health nurses’ engagement in policy: one which puts public health nurses, as actors in the policy process, at the centre of the investigation. The overall philosophical lens through which the research was conducted was critical social theory and the methodology was a grounded theory influenced research design. The study adopted a three stage data collection and analysis process: primary data (questionnaires and interviews), detailed policy analyses of two specific White Papers and secondary data (extant documents). The data were collected and analysed through a grounded theory approach in order to answer four research questions: 1. What do public health nurses know about policy, specifically in relation to two English Department of Health White Papers: Creating A Patient-Led NHS (DOH 2005) and Our Health, Our Care, Our Say (DOH 2006)? 2. How do they engage in the policy process? 3. What affects their implementation of policy? 4. Is there a policy-practice gap? A triangulated approach to data collection and analysis was used. Primary data were collected through questionnaires and follow up telephone interviews with public health nurses (health visitors and school nurses) in four PCTs and one social enterprise in five different geographical areas of England. Further data from detailed policy analyses using frameworks by Popple and Leighninger (2008) and Walt and Gilson (1994) were also considered. Finally, secondary data from extant documents including newspapers, websites and organisational documents were reviewed. At the end of the research process, it was possible to answer the four research questions. In addition to this, new knowledge and theory emerged around three main themes: i) A proposal for a new combined framework for policy analysis which leads to a comprehensive and analytical account of policy content and context combined with a detailed consideration of the role of public health nurses as actors in the policy process. ii) Theories as to why and how public health nurses lack influence in the policy process. iii) Analysis of the effect of lack of resources on inhibiting practice innovation in response to policy agendas. Consideration of these theories led to several recommendations for practice. Throughout the research process, there was continued interaction between the three phases of data collection, analysis and theory development.

Despite widespread endeavours over many years, patient-centred care continues to evade some areas of healthcare. This can be clearly evidenced by regular reporting of sub-standard care and the findings of national patient experience surveys which repeatedly highlight a number of common contributory factors. Amongst these include a predominant culture of secrecy and blame rather than openness and support; failure to listen and respond to staff or patient issues; workloads and time constraints; fragmented teamwork; an overriding focus on targets rather than people; in addition to varying perceptions and interpretations of, and expectations and priorities for patient-centred care (PCC). These occur between patients, staff, educationalists, policy-makers, healthcare managers and the public. These factors, which are further reinforced by this study’s review of empirical studies of patient-centred care, strongly indicate that new approaches to improvement, that involve service providers as well as service users, are called for. Addressing this call was an interest of this study. Action research was selected because this promotes a collaborative and democratic approach to research-based organisational, social and cultural change and improvement. In this study, which was also underpinned by the philosophy of patient-centred care, action research was combined with the Patient Journey. This is a patient-centred improvement, and, or, practice development process developed and tested by Campbell et al (2004) at the City Hospitals Sunderland NHS Trust. By combining the action research and Patient Journey (PJ) processes, this enabled the generic potential and effectiveness of the approach to be concurrently investigated and established as will be explained. Through the collaborative efforts of a participating 25 member Vascular Patient Journey project team, data was gathered during the process through team discussions, mapping and interviews with 17 service users. 75 issues were identified using inductive thematic analysis; 34 of which emerged from the data of service users, 35 from service provider data, and a further six jointly emerged from both datasets. These provided powerful catalysts for change and points of learning which the team, empowered by their involvement in the process, used as the evidence-base from which to action change, as discussions in this thesis will demonstrate. They will also illustrate why more should be done to involve multidisciplinary teams as well as service users in improvement.

This thesis presents a body of publications in the area of critical care nursing, for the consideration of the award Doctor of Philosophy by publication. The publications and their dissemination herein contribute to a new and original body of knowledge within critical care nursing practice. This thesis aims to demonstrate how an original contribution to the advancement of critical care practice has developed through an on-going integration of academic and practice work and has led to the development of a model for advancing practice. Based on the know-that and know-how framework of advanced knowledge, consideration is given how this approach could be better developed to incorporate other dimensions attributed to experiential learning, namely pattern recognition and an exemplar of the knowing-how knowing-that framework is offered. However, it emerged that there are problems with advancing practice because it is considered the work of the advanced practitioner, yet it is contended that there needs to be a process which allows individuals to advance their own practice. Therefore, it was necessary to develop a working definition of advancing practice not only to map professional advancement of critical care nursing practice and how published works illustrate this, but to offer model of knowledge integration based around theoretical, practical, reflective and reflexive practice and supervisory support to enable individual practitioners the framework to advance practice. This thesis is presented in three chapters: Introduction, Body of Work and The Way Forward. In the first chapter, an overview of the origins and trends of advanced nursing practice and the emergence of advancing nursing practice in critical care. The purpose of this first section, however, is not to engage in the politico-professional debate on the meaning of advanced practice, because this is well developed within the literature, but is to set the scene in the context of published work. By using a narrative approach as a journey of personal discovery, a description of how published works illustrate progress in this respect and show the advancing of critical care practice.The second chapter not only comprises publications with regard to critical care nursing practice but also presents a detailed critique of these publications and their contribution to advancing critical care nursing practice and knowledge. Moreover this discussion identifies three themes which are further developed into the classification of knowledge attributable to advancing practice. In the concluding chapter, recommendations for the way forward are discussed with the development of a critical care nursing knowledge integration model. An exemplar of the model demonstrates that advancing practice in critical care is a continual process of development, analysis and practice that advances the knowledge and skill of critical care nursing. More importantly, it is the integration of all these facets that allows for the growth of the individual to become an advanced practitioner. In summary, this thesis represents a portfolio of work that makes an original contribution to critical care nursing knowledge. The product of this thesis is the development of a knowledge integration model as the basis for advancing practice:"

This research project explores nurse practitioners' experiences of role transition and professional autonomy, aiming to gain a new understanding of how nurse practitioners experience their role, and seeking new insight into the potential of the nurse practitioner role in the ever changing arena of health care delivery. The study addresses the concept of professional autonomy, and the boundaries of professional practice, and links this to the legal, ethical and epistemological foundations of nursing practice in general, and more specifically to the professional role of the nurse practitioner. Amongst specialist nursing roles, the position of the nurse practitioner is of particular interest, because nurse practitioners have evolved within an interprofessional philosophy of care, and therefore have complex issues relating to the scope of their professional practice, their individual and professional identity, and their professional autonomy. The research was conducted using a phenomenological hermeneutic approach inspired by Ricoeur (1976, 1981), and placed a significant emphasis on the meaning of the lived experience of the participant nurse practitioners within their professional role. Narrative interviews with fourteen nurse practitioners were transcribed to create a series of texts for subsequent analysis. Data analysis provided a progressive exploration of the meaning of the experience of professional autonomy for the participants in the study, and incorporated a descriptive analysis and an interpretive account of the phenomenon. From this hermeneutic analysis a new interpreted sense emerged, and a comprehensive understanding of the meaning of the phenomenon under review could be formulated. The findings reflect a generally positive view of practice on the part of nurse practitioners, but highlight a number of barriers to the development of their professional autonomy. Professional relationships are central to the experience of professional autonomy, and the future development of the nurse practitioner role. The findings reinforce the need for clearer definition of the nurse practitioner role, and suggest that further reflection on the nature of advanced practice, and the relationship between nurse practitioners and the wider profession of nursing might help in this regard.

Background: Childbirth is popularly considered to be a time of happiness and fulfilment, yet many authors have reported that women express more negative feelings, including anxiety, apprehension, self-doubt and guilt requiring significant emotional and psychological adaptations during pregnancy and postpartum than at other times in their lives. Yet, despite evidence of emotional stresses challenging women in the perinatal period, one largely unexplored factor is how the management of this complex range of emotions impacts on maternal psychological health. If managed inappropriately emotions evoked by stressful events will intrude on the maintenance of everyday behaviour. The Emotional Processing Scale (EPS), a tool developed to measure the management of emotions and validated in a variety of countries worldwide, identifies poor processing. To understand maternal emotions more fully this study has used the EPS to explore relationships between emotional processing during the life-changing events of pregnancy and birth and the emergence of postnatal depression. Aims: The study aimed to examine the relationship between the way women managed their emotions during pregnancy, as measured on the EPS and the development of postnatal depression, as measured on the Edinburgh Postnatal Depression Scale (EPDS). It also investigated the possibility of predicting postnatal depression from scores on the EPS in conjunction with other recognised risk factors. Methods: A cohort of 974 pregnant women, aged 16 to 44, from the South of England were surveyed at 13 and 34 weeks gestation and 6 weeks postpartum. In addition to demographic information, standardised measures included the EPS, the Edinburgh Postnatal Depression Scale, the Short –Form 36 and the Rosenberg Self-Esteem Scale. Data were analysed using a variety of univariate and multivariate techniques to investigate the inter-relationships between these variables. Multiple and logistic regression models were built to determine which variables measured during pregnancy best predicted postnatal depression. Findings: Strong associations were found between poor emotional processing and the likelihood of developing postnatal depression. After adjusting for other recognised and established risk factors for depression, poor emotional processing in early and late pregnancy made a strong unique contribution to the prediction of postnatal depression and the odds of women with a high EPS scores in early and late pregnancy developing depression postpartum were 2.5 and 3.4 times greater than women with low EPS scores. Implications: There is a need for professionals to have a greater understanding of emotional processing. It is easily measured, and integration of emotions assessment together with supportive measures to facilitate women to manage their emotions more effectively into the existing framework of antenatal care could enable the strategy to be undertaken in a resource-efficient way. This could benefit families who might suffer from the detrimental impact of maternal perinatal emotional and psychological disturbances.