For midwifery practitioners, the concept of excellence is central to the ethos of quality midwifery care (DH 2009, NMC 2009) and although midwives are being asked to aspire to ‘a standard of excellence’ (DH 2009), the meaning of ‘excellence’ for both women and midwifery practitioners has not been defined. The focus of this study is to understand excellence at a personal level, what makes some midwives ‘stand out’ and what it means to ‘be’ an excellent midwife, from the service users perspective.

This work grew out of a need to try to understand my often experienced sense of being misunderstood, misrepresented and marginalised. A prerequisite to helping others in mental health nursing is arguably some requirement to understand one’s self. But who is the self? In this thesis I use an autoethnographic approach to examine how the self, multiple selves and identity formation is socially constructed. Social constructionism contends that categories of knowledge and reality are actively created by social relationships and interactions. As an autobiographical genre of writing, this evocative autoethnography has been written in the first person displaying my multiple layers, connecting my selves to the cultures I inhabit. As a reflexive methodology it offers the researcher a means of critically exploring the social forces and discursive practices that have shaped his own cultures. In addition I discuss the contrast between traditional guidelines and protocol driven ethics with more progressive relational ethics. Central to relational ethics is the question ‘What should I do now?’ rather than the statement ‘This is what you should do now.’ I continue by arguing that we use stories as ‘equipment for living’, as tools to understand, negotiate and make sense of the many different situations we encounter. In recent years, as part of the ‘narrative turn’ in the social sciences, a growing number of scholars have suggested that we live in a world shaped by these stories. I discuss connections between the cultures people occupy and how an individual’s reflexivity can keep them stuck or liberated and emancipated with regard to their personal narratives. Whilst the text is not intentionally instructional, storytelling can be instructive. By showing my vulnerabilities the work is a prism for the reader to reflect on their narratives and the cultures they inhabit.

Breech birth has become a rare phenomenon in England over the last two decades. 3-4% of all babies present bottom or feet first at full term (37-42 weeks gestation) and despite conflicting research about the safest mode of delivery for breech presentation, the vast majority of breech babies will be delivered by planned caesarean section. The small number of qualitative research studies suggest that the experience of breech has complex meanings for childbearing women. This research intended to explore these elements further and to better understand this experience within a social, cultural and gendered context.

This study explores the introduction of an approach called Pre-Therapy to staff working with people with dementia. Pre-Therapy contributes to the existing range of therapeutic approaches which aim to engage with the subjective experience of the world of people with dementia who have severe difficulty communicating. Pre-Therapy aims to facilitate engagement and create relationships with people who are traditionally seen as beyond contact or out of reach. The approach involves using contact reflections. The worker reflects back to the person their words, facial expressions, actions and surroundings. Until now, the application of Pre-Therapy to dementia care has not been explored in depth. An Action Research process examined the research question - What happens when staff learn and use Pre-Therapy contact reflections with people with dementia? The question involved three aspects: the response of people with dementia to contact work, the use of contact work by staff, and the learning process undergone by staff. Underpinned by values of inclusion, participation, democracy and collaboration, the study demonstrates joint inquiry and cyclical exploration. The research process involved self-participation, participation with health care staff and engagement with an expert community (The International Pre-Therapy Network). The entire research process spanned five years. Eleven staff in three residential settings participated as colearners for 18 months of the process. Located in the real world context, the study accommodated organisational flux, service instability and changes of personnel in a climate of modernization and reorganisation. Data were generated through observation, which included 14 hours of video recordings of interactions, and ongoing dialogue with health care staff and the expert community. The analytic process accompanied the research activity, using comparative analysis and Schatzman's Dimensional Analysis. Findings indicate that Pre-Therapy Contact Work has the potential to add to existing approaches in dementia care, facilitating greater self-expression of the experience of the subjective world of the person with dementia and promoting greater communication with workers. However, minor adaptations of the approach are indicated. Despite the apparent simplicity, contact work challenged staff. Barriers to learning and using contact work arose from intrapersonal, interpersonal and contextual factors. Factors which mediated the learning and use of contact work led to the emergence of a theoretical model of the emotional management of interactions. Resting on theories of constructed role identities, the model contains two contrasting positions: the emotional custodian and the emotional container. The thesis proposes that the model may be part of an underlying social process around maintaining emotional social order in interactions with people with dementia. In turn, this may help understand difficulties workers face when engaging in the emotional world of people with dementia and enacting values of being person-centred which are inherent in the policy and literature.

Liberating qualitative research findings from the dusty shelf of academia: developing a translational methodology illustrated by a case study of the experience of living with dementia. The exponential growth of qualitative health and social care reports in recent years has generated a dialogue about the utility of qualitative research findings. The traditional methods of dissemination often result in the findings remaining on 'the shelf' with the result that they have little impact on practice, policy, or members of the public. In this study I develop a generic framework for synthesizing and communicating qualitative research findings that are already in the public arena. The framework is comprised of four stages: - Stage 1 is a strategy for identifying relevant and useful studies in the area; Stage 2 develops relevant and useful criteria for selecting studies: the quality of a study is assessed by its; substantive contribution, aesthetic merit, reflexivity, impact and expression of reality; Stage 3 draws upon the philosophy of phenomenology and hermeneutics as a way of synthesising the selected studies, providing an experiential description of the phenomenon of interest (called a structural textual synthesis). Stage 4 offers principles by which the structural textural synthesis can be transformed and communicated to lay audiences in more aesthetic and understandable ways. The above framework is applied to the phenomenon of living with dementia from the perspective of the partner with dementia and their care partner. The structural-textural synthesis is transformed into a script, which has been performed, and recorded on DVD. The transferable implications of this framework are considered for their potential to communicate qualitative research findings already in the public arena to the public in ways that facilitate understanding and empathy

Women's experiences of their perineum following childbirth: expectations, reality and returning to normality The aim of the study was to explore the feelings, perceptions and experiences of women in relation to their perineum following childbirth in the early postnatal period. A grounded theory approach was used for collecting and analysing data from eleven diaries and seven interviews with broad questions about how the perineum, following a vaginal birth, affected the way daily living activities were carried out. Initially purposeful sampling was utilised to recruit women but as important issues emerged recruitment continued through theoretical sampling. Following childbirth women expressed a strong desire to get back to normal reflecting the core theme `striving for normality'. Normality in this context meant doing normal things and feeling like their normal selves. Much of what the women described doing during the early postnatal period was related to achieving that goal and linked to the following categories: `preparing for the unknown', `experiencing the unexpected', `adjusting to reality', `getting back to normal' and `recovery of self'. The main theoretical idea that emerged from this study and derived directly from the data is that: If women are able to successfully adjust to their new and often unexpected reality after the birth of their baby, and begin to reclaim their selves and their world, then they experience a return to their normality. The data demonstrates and clarifies three distinct but related aspects. Firstly, coping with the unexpected consequences of childbirth meant that the women frequently made adjustments to how they carried out essential activities such as walking, sitting and passing urine, in order to try and carry on as normal. The second aspect related to daily activities that were not essential but which women felt necessary to undertake because of social expectations. These included housework and shopping. The third aspect related to how the women felt about their body as a result of the perineal trauma they sustained, and what helped them to feel like their `normal selves' again. These interrelated stages form a framework that reflects Maslow's lower order, hierarchy of needs, within the humanistic psychology paradigm. Implications for practice include the need to improve care in areas of preparing women having their first baby, listening to women as part of the assessment of perineal pain following birth and the need for continuity of care from the same midwife in order for women to appropriately manage their perineal experience.

A small percentage of mentally ill patients, sometimes referred to as 'revolving door' patients, are frequently readmitted to psychiatric hospitals. This study explores how these patients construct meaning and reality and how this enacted reality provides a context for shaping their identities. The study draws on mental health policy, political ideologies and the history of deinstitutionalisation in order to illuminate this problematic phenomenon. The study is framed within the social sciences, but more specifically within the fields of mental health and social work practice. The methodology is qualitative, placing emphasis on a hermeneutic phenomenological approach. The foundation of the study is underpinned by a social construction and social psychology framework. A unique minimalist interview technique based on the Biographic Narrative Interpretive Method is used for data collection and analysis. Data from seven interviews with participants are presented followed by the researcher's reflections on the interviews and post-interview process. The life stories of four of the seven participants are analysed by using reflective teams. The lived life, or chronological chain of events as narrated, is analysed sequentially and separately. The told story, or thematic ordering of the narration, is then analysed using thematic field analysis; this involved reconstructing the participants' system of knowledge, their interpretations of their lives and their classification of experiences into thematic fields. An integrated procedure of abductive and inductive analysis of the stories elicited from participants offered immense potential for constructing meaning. Perspectives on 'revolving door' patients have often regarded them as having a one-dimensional life. This study revealed that these existential lives are complex and diverse and exist within a cultural matrix of social and psychological constructs. Interpretations of these patients' experiences illuminate the complexities arising from multiple admissions to psychiatric hospitals and highlight the problematic aspects which impact their socially constructed identities. These case studies of 'revolving door' patients' personally narrated lives extend the social psychological study of self/identity and contribute to the field of mental health research.

Pre-eclampsia is an enigmatic multisystem disorder of the second half of pregnancy. Placental hypoxia and generalised endothelial dysfunction are features of this syndrome and the clinical manifestations of this disease are suggestive of reduced maternal tissue perfusion. There is convincing evidence that the hypoxic placenta released as yet unknown circulating factor(s), which rsult in the generalised endothelial dysfunction. The hypothesis of this study is that, altered expression of hypoxia regulated genes occurs in the placenta and vascular endothelium in pregnancies complicated by pre-eclampsia which accounts for the clinical manifestations of the syndrome including the reduced blood flow. There is an ongoing debate regarding the shared and disparate components of the pathophysiology of pre-eclampsia and Intra uterine growth restriction (IUGR) hence women with IUGR pregnancy were also included in this study. The primary aim of this research was to identify, through bioinformatics a set of hypoxia regulated genes in pre-eclamptic placenta and then to validate the results through RT-qPCR from the placenta and also in edothelial cells exposed to the plasma from three groups of women (pre-eclampsia, IUGR and normal pregnancy) recruited for the study. First, Strain gauge plethysmography was used to measure maternal tissue blood flow in the claf, which was compared to tissue oxygen saturation measured using pulse oximetry in the three groups of women. Second, using bioinformatics, a set of novel potential hypoxia regulated genes namely angiogenein inhibitor, apolipoprotein E, growth differentiating factor (GDF15), HS19, KISS1, NAD-Ubiquinone oxidoreductase 1 (NDUFAB1) and ROBO$ were identified and RT-qPCR was used to study their expression in the placenta and also in the two endothelial cell lines, (Human umbilical vein endothelial cells and Myometrial uterine microvascular endothelial cells) exposed to hypoxic conditions and plasma from the threee groups of women. Calf blood flow was significantly decreased in women with pre-eclampsia however the difference was not statistically significant in women with IUGR pregnancy compared to normal pregnancy. Notably, tissue oxygen saturation was not significantly different between the three groups of women and there was no correlation between tissue blood flow and oxygen saturation in all the three groups. Overall, the expression of the novel hypoxia regulated genes was increased in pre-eclamptic placenta compared to placenta from normal pregnancy. There was an overall reduction in the expression of the hypoxia regulated genes by HUVEC exposed to plasma from women with pathological pregnancies. However there was no change in expression of the hypoxia regulated genes by UtMVEC when exposed to similar conditions. The study findings suggest that in pre-eclampsia there is compensatory up-regulation of hypoxia regulated genes in the placenta probably in response to uteroplacental ischemia. In both pre-eclampsia and IUGR, there is a failure of up- regulation of hypoxia regulated genes in maternal endothelial cells cultured in vivo in response to circulating factor(s) released by the hypoxic placenta and this may explain the clinical manifestation of impaired tissue perfusion.

The purpose of this study was to develop a theory in order to explain the meaning and process of learning the role of the midwife from midwives in the clinical setting. To achieve the depth and detail required in the absence of literature on this topic, the grounded theory approach was adopted. The sample consisted of twenty student midwives and seventeen midwives. Data were collected by means of unstructured interviews which were tape-recorded. Each participant was interviewed on a minimum of two separate occasions. The constant comparative method was used to analyse the data. The findings of the research contribute to knowledge by making explicit how the role of the midwife is interpreted and enacted, the effect this has on what role students learn, how it is learned and hence how the role is transmitted from one generation of midwives to the next. The `emic' perspective facilitated the emergence of a number of theoretical ideas. Central to these are the rules of practice. When midwives rigidly follow written and unwritten rules they prescribe midwifery care which corresponds to the medical model. In doing so they act as obstetric nurses or handmaidens to the doctor. When everything is interpreted as rules to be followed prescriptive midwives appear to be uncaring and detached from the experience of childbirth. The individual needs of women are not met and the relationship between midwife and client is superficial. Midwives who rigidly follow the rules inhibit the growth and development of students providing them with few opportunities to achieve beyond the level of their role model. Midwives are flexible when they interpret the rules for the benefit of women and provide a woman-centred model of care. These midwives therefore act as autonomous practitioners. When rules are interpreted and adapted to meet the needs of women, flexible midwives demonstrate involvement in women's experiences and are empathic, supportive and caring. Midwives who use professional judgement to interpret the rules provide an environment in which senior students can become autonomous practitioners. When midwives demonstrate the role of autonomous practitioner, practise a woman-centred model of care and meet the learning needs of students, they are appropriate role models and teachers. There is conflict in the clinical setting when practitioners who hold opposing attitudes, values and beliefs practice together. Conflict can be avoided when flexible midwives adopt strategies that involve becoming prescriptive or practising by subterfuge. In accordance with Bandura's social learning theory students learn by observing and emulating the example of their role models. Learning is vicarious when students observe the consequences of their role models' actions. When learning the role from a role model is interpreted as a passive process, a behaviourist and pedagogical approach to learning and teaching ensures perpetuation of the obstetric nurse role that is no longer considered acceptable. Role modelling serves as a vehicle for transmitting new behaviour when learning is perceived to be an active process. In this case a humanistic, andragogical and cognitive approach to learning and teaching is adopted giving students the freedom to determine their own role. Practice from a number of role models is emulated. In this way each midwife acquires a unique identity which is derived from an abstract role model rather than a particular person. Students are prepared for the autonomous role of the midwife, and it is this role they wish to emulate.

This study examines labour ward culture on two British labour wards, in terms of mother-baby contact and breastfeeding, which has not been empirically researched since 1985 (Garforth & Garcia 1989). ‘Aims’: to investigate the organisational culture; examine mothers' beliefs and experiences; and midwives' knowledge, beliefs and practices. ‘Objectives’: To compare organisational cultures; identify if midwifery practice is evidence based and factors which facilitate or detract from it; identify mothers' preferences, beliefs and levels of satisfaction. ‘Study Design’: Ethnography with case study and diagnostic analysis also utilised. Methods: observation and interviews: purposive sample of mothers (n = 50) and midwives (n = 51); interviews with Heads of Midwifery (n = 2); focus groups with midwives (n = 3); and documentary analysis. ‘Results’: Despite Trust strategies and Heads of Midwifery support for evidence-based practice, clinical guidelines and midwifery beliefs about mother-baby contact and early breastfeed were not usually congruent. Mother-baby contact after birth is usually interrupted for completion of tasks and some babies have multiple contact episodes, which has not been previously described in the literature. Completion of routine tasks for transfer of mothers and babies to postnatal ward takes precedence, because of organisational demands and insufficient resources. However, most mothers expressed feeling satisfied with contact achieved and support for breastfeeding. ‘Conclusion’: Findings of the study have contributed new insights and knowledge of labour ward culture. It is not conducive to uninterrupted mother-baby contact and is not evidence-based. ‘Recommendations’: The development of a learning culture and clinical leadership to promote evidence-based practice and woman-centred care is recommended. The unique period after birth should not be disturbed, to prioritise routine tasks.