Consultant nurse and midwife roles, with the expectations of significantly moving forward the professions in relation to practice development, effective leadership and quality care provision, have been a major UK policy initiative since 2000. Whilst consultant nurses have received much attention, consultant midwives have been relatively little researched. This study aimed to explore the intricacies of the consultant midwife role. Using an in-depth qualitative case study design, the roles of eight consultant midwives across eight NHS Trusts in England were studied. Data were collected via in-depth interviews with consultant midwives, their heads of maternity services and consultant obstetricians; additionally, the consultant midwives were observed in practice and documentary evidence (their job descriptions) were examined. Data were analysed thematically and aggregated, revealing three dominant themes related to clinical wisdom, taking control and shaping the future. Findings showed that the consultant midwife is in a position of power, built on a foundation of clinically acquired wisdom, transformational leadership skills and a belief in woman centred care, essential to a profession fit for the future. Individually and collectively, the consultant midwives conveyed a passion for their role, whilst aware of the demands of their position. Their impact lay in relation to the way they used their experience, skills and understanding, to undertake complex roles in practice, juggling responsibilities to effect change and improve services for childbearing women and their families. Their strength was born out of acquired knowledge and expertise, as leaders and as role models, influencing not only practice but the midwives of the future. This thesis provides the first in-depth exploration of the consultant midwife role and as such greatly strengthens the hitherto limited evidence base. As well as focusing on the particular aspects of day-to-day consultant midwifery it also gives detailed recommendations for further development of the role organisationally.

Older people are the world’s fastest growing population group. By 2050 eighty per cent of older persons will live in what are now developing countries. There is established and growing evidence of the difficulties families in developing countries are experiencing in providing adequate support for their older members. This thesis explores how international development is responding to the interests of older people. The research examines how older people are represented in international development discourse and illustrates the impact of this on practice. This is informed by a comparative analysis with the progress of women in development. A critical discourse analysis of a corpus of texts from intergovernmental agencies illustrates the degree of visibility of older people in the development discourse. A case study of the work of inter-government organisations in West Bengal, India, shows how this can impact on grassroots activity. An original conceptual framework is introduced which aligns the dominant development paradigms with the dominant perspectives on older people emerging from this research. To the best of my knowledge this is the first research study to consider the (in)visibility of older people in international development discourse and to look at its implications on policy and practice. It highlights that a concentration of development resources at one end of the age spectrum to increase life expectancy is being met with an absence of planned support to meet the consequences when people successfully reach old age. The research further shows that when visible, older people are generally viewed as a homogeneous group in need of support and care, and not as citizens able to contribute and participate in development. The research illustrates a connection between global discourse and local practice in relation to older people and indicates a need for further studies to assess the extent of the links and to examine how local practice could inform the international development discourse.

Nursing scholarship and healthcare policy set an expectation that nurses should think about patients as persons. Nevertheless, the literature reveals that critical care nurses can struggle to perceive patients as persons, and thus suggests they may think about patients in different ways. This thesis presents the findings of an ethnographic study undertaken within one critical care unit in the United Kingdom which examined how critical care nurses do think about patients. A purposive sampling strategy recruited 7 participants representing both experienced and inexperienced critical care nurses. Data were collected over a period of 8 months during 2006 to 2007, and primarily comprised the field notes from 92 hours of participant observation supplemented by 13 tape recorded interviews. Data analysis was influenced by Foucault and Goffman and adopted the perspective of linguistic ethnography. Analysis revealed that all participants thought about patients in seven distinct ways: as ‘social beings’, as ‘valued individuals’, as ‘routine work’, as a ‘set of needs’, as a ‘body’, as ‘(un)stable’ or as a ‘medical case’. Accounts of participants’ practice revealed that they had a tacit understanding that these different ways of thinking related to aspects of one coherent whole, but no one way of thinking could be characterised as thinking about this ‘whole person’. Nurses could only think about one aspect of the patient at a time. Nurses’ practice was not guided or explained by their thinking about patients as persons, but rather expert practice was characterised by nurses’ fluid and appropriate movement between different ways of thinking about patients. When participants talked about their practice it was evident that these nurses could only legitimately talk about themselves as giving care to persons. Participants characterised some of the ways in which they had to think about patients as impersonal, and this actively hindered these nurses from describing or reflecting upon elements of their practice. There is therefore conflict and dissonance between nurses’ expectation that they should think about patients as persons, and the fact that delivering nursing care requires them to think about patients in different ways. The development of future critical care nurses will require practitioners and educators to recognise that nurses think about patients in different ways, and that expert practice is characterised by the clinical wisdom which enables nurses to think about patients in ways which are appropriate to the moment. Nurse scholars and educationalists should therefore avoid claims to a unique professional knowledge base which suggest to nurses that some ways of thinking are always inappropriate or inherently reductionist. Instead, there is a need for scholars and policy makers to articulate a vision of person centred care clearly, and in ways which avoid constructing dissonance between nurses’ ideals, and the ways in which they do and must think about patients.

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Analysis of breathing pattern can quantify parameters of breathing such as rate, volume, timing and regularity/rhythmicity. This information can be useful to compare breathing patterns in those healthy and with disease, under different experiment conditions (such as rest versus activity) and to monitor changes over time. In this research, respiratory inductive plethysmography (RIP) was used to record breathing patterns in a group of healthy subjects and a group of severe asthma patients. RIP is a leading technology for ambulatory monitoring of breathing, but traditional RIP devices suffered from poor signal quality under such conditions due to movement of the sensor. Several authors have also raised doubts about the existing calibration methods for RIP which can lead to inaccurate estimation of breathing parameters. During the first phase of the programme, an instrumented garment (LifeShirt®) which had RIP embedded within was tested for its validity in comparison to a pneumotachograph (PT). The first study sought to validate the measurements obtained from the LifeShirt ®against PT when calibrated with a published but yet to be tested method for breath by breath analysis and to address the limitations of existing calibration methods. Eleven healthy individuals took part in this first study. Breathing patterns were simultaneously monitored by the LifeShirt ® and the PT during thirty minutes of rest and twenty minutes of exercise. Parameters of tidal volume, expiration time and tidal volume variability were recorded and compared between devices. The analysis from the first study demonstrated that RIP recorded proportionate changes of tidal volume and expiration duration relative to PT during quiet breathing and exercise. Mean tidal volume and expiration duration between devices was strongly correlated for rest and exercise. No statistical difference in tidal volume variability was observed between devices during either period. Significant differences in expiration duration between devices were observed in all participants at rest but not during exercise. Results of this first study demonstrated that valid breath by breath analysis using RIP without PT was feasible. This is clinically advantageous due to simplicity of set-up for RIP. In the second phase, measurement of breathing patterns was made in severe asthma patients with the LifeShirt® alone during thirty minutes of rest. It intended to add new knowledge with regards to the breathing patterns within this small population as compared to the healthy population. Ten healthy individuals and ten patients diagnosed with severe asthma took part in the second study. Breathing parameters of tidal volume, inspiration time, expiration time, end tidal carbon dioxide levels, tidal volume variability and end tidal carbon dioxide levels variability were recorded by the LifeShirt®. The analysis of the second phase shown no evidence that breathing pattern parameters could differentiate between the severe asthma patients and healthy volunteers in our small study. The symptoms of hyperventilation found more commonly in the severe asthma group were not associated with differences in breathing pattern parameters. However, considerable differences were found between individuals. This suggests the existence of individuality in breathing patterns between individuals. Such findings raised doubts as to whether there is a group ‘pattern’ that is common within the severe asthma population or within the healthy population. This programme calls for a change in paradigm to consider breathing patterns as an unique individual ‘trait’ rather than as a group characteristic.

This cross-national comparative study aims to explore previous changes and future trends in nursing in England and mainland China, and the impact that reform has had on the way in which nurses are currently and prospectively educated in the two countries. Nursing education in both countries has experienced considerable development related to societal, health care, and technological advances, alongside economic growth. In England, there is a policy imperative to shift nursing to an all-graduate discipline and a need to look at the balance of the health care workforce. In mainland China, there is a goal to educate nurses who are fit for the changing healthcare system, during a period of health care reform which attempts to improve primary health care delivery in rural and urban areas. A case study design has been adopted in two settings, one nursing school in England and one in mainland China. Participants are those involved in the provision of nursing education – the nurse teachers. In-depth data were collected by interviews from 11 people in the English site and 10 in the Chinese site. Thematic analysis was used to analyse the data. These data are set within the historical and contemporary contexts, through an analysis of the literature. Findings indicated that the trajectories of the development of nurse education in the two countries are varied, but with interesting similarities and differences. For example, the professionalisation of nursing in the two countries has followed a pathway that is comparable in some senses but not others. This is related to such issues at the inter-relationship of medicine and nursing and views about the status of nurses. Main conclusions of this study include the increasing emphasis on community care and the linked need for further curriculum development to prepare nurses in both countries for such changes.

Childhood sexual abuse is a major, but hidden public health issue estimated to affect approximately 20% of females and 7% of males. As most women do not disclose to healthcare professionals, midwives may unwittingly care for women who have been sexually abused. The purpose of this study was to address the gap in our understanding of women’s maternity care experiences when they have a history of childhood sexual abuse with the aim of informing healthcare practice. This narrative study from a feminist perspective, explored the maternity care experiences of women who were sexually abused in childhood. In-depth interviews with women, review of their maternity care records and individual and group interviews with maternity care professionals were conducted. The Voice-centred Relational Method (VCRM) was employed to analyse data from the in-depth interviews with women. Thematic analysis synthesised findings, translating the women’s narratives into a more readily accessible form. The main themes identified were: narratives of self, narratives of relationship, narratives of context and the childbirth journey. Medical records provided an additional narrative and data source providing an alternative perspective on the women’s stories. Silence emerged as a key concept in the narratives. This thesis contributes to ‘Voicing the silence’. The particular contribution of the study is its focus on the women’s voices and the use and development of VCRM to listen to them. It highlights where those voices are absent and where they are not heard. Women want their distress to be noticed, even if they do not want to voice their silence. The challenge for those providing maternity care is to listen and respond to their unspoken messages and to hear and receive their spoken ones with sensitivity.

Whilst national guidelines have recommended abstinence before 18 years of age, in the North West of England, the use of alcohol is common practice by 15 years. The related harms amongst young people (such as violence, regretted sex, hospital admission) place significant burdens on public and individual health. Public health data are vital in order to monitor levels of harm and evaluate prevention strategies. This PhD submission presents a series of peer-reviewed journal articles (and other supporting publications) which evidence how I have used original research to further understand alcohol misuse and its impacts on at-risk groups such as underage drinkers, heavy episodic drinkers and those who may have been drinking alcohol during pregnancy. I have used a number of novel methodologies to explore alcohol consumption and further understand the need for early intervention. Firstly, we used simultaneous surveys of parents and children to understand both the child’s consumption and their parents’ understanding of their child’s consumption. Secondly, we used English hospital admission data to explore for the first time the prevalence of Foetal Alcohol Syndrome and related disorders. Thirdly, we initiated a feasibility study to understand the potential reach of a community-based alcohol brief intervention and liver blood test. Finally, we used a combination of breathalyser readings and nightlife surveys to increase the accuracy of surveys of nightlife users. The articles presented in this PhD provide a significant contribution to public health knowledge on the epidemiology of alcohol consumption and related harm, as well as discussing the evidence base for effective prevention strategies. This submission considers the methodologies, findings and impacts of my research. The work for all publications was undertaken during my employment at Liverpool John Moores University.

Mass gatherings such as the Olympic Games pose unique challenges for interorganizational collaboration. Such events often bring together organizations that collaborate irregularly or have never engaged in joint working. They involve interaction and collaboration among multiple and diverse agencies aiming at delivering a service to a large clientele, which can often prove challenging. This study used the 2012 London Olympic Games as the empirical setting to examine the interagency collaboration among the multiple and diverse public health and safety organizations involved in one of the world's largest mass gatherings. A single, holistic and exploratory case study design was used and data were collected before, during and after the Games through 39 semi-structured interviews with key informants, direct observations of field exercises and documentary analysis. Data collection commenced in May 2011, 14 months before the actual Games, and was completed in October 2012, two months after the completion of the Games. Template analysis was used to thematically analyze the interviews' transcripts, the fieldnotes from observations and the documents. Findings discuss interagency collaboration in mass gatherings along three main activity domains: leadership, communication and learning. In each domain, a number of challenges and facilitators emerged influencing interagency collaboration. Regarding the leadership domain, the lack of engagement of the leading organization and the ambiguous interoganizational decision-making processes negatively influenced collaboration. Shared micro-level leadership and the use of interorganizational linkages enabled collaborative working. Experienced positional leaders of each organization enabled the decision-making process at the interagency operational level by exercising a range of interpersonal leadership capabilities including flexibility and the ability to negotiate. Codified frameworks at the organizational level also provided leaders with common ground to assist them manage the complex interorganizational processes. Within the second domain, the complex intraorganizational structure of the involved agencies and the high density of information transmitted were associated with a dysfunctional communication experience. Findings revealed that the crafting of boundary-spanning roles and intense face-to-face interaction positively contributed to interagency collaboration. Online information systems and formal intersectoral dissemination of reports were essential in gaining common situational awareness. The implicit cultural rules in the form of communication etiquette shaped how interorganizational collaboration was perceived. Finally, sharing the acquired knowledge was a necessary step to create an enabling collaborative environment among interacting organizations. Experiential learning was identified as a significant factor which helped promote joint understanding and partnership work. Informal interpersonal exchanges and formal knowledge transfer activities facilitated knowledge sharing across interorganizational boundaries, helping to break down silos. The study outlines challenges and strategies that shaped interagency collaboration in the context of mass gatherings. Practical implications arising from this study inform the ways organizers of mass gatherings, public health and safety agencies and professionals can engage in effective partnerships and joint working.

Background: Kuwaiti female adolescents have a substantial prevalence of physical inactivity and unhealthy diet leading to epidemic proportions of obesity. Additionally, rates of tobacco smoking and substance abuse are increasing among them. There is a lack of health promoting interventions to deter such behaviours in this population and therefore a knowledge-based intervention in a school setting was investigated. Methods: The study included 128 adolescent females between the ages of 14 and 18. They were randomly selected and allocated to an intervention group (n= 64) and a control group (n= 64). The intervention consisted of six educational sessions for each of the following: physical activity (PA), healthy nutrition, prevention of tobacco smoking, prevention of substance abuse, bone health, and sun protection. Both groups were assessed before and after the intervention in weight measurements, physical fitness, PA by accelerometry in a subsample, and self-reported behaviours. The self-reported behaviours included PA, dietary behaviours, tobacco smoking, substance abuse, and sun exposure and protection. In addition, the knowledge of each health topic was assessed immediately before the session and a week after. A mixed model repeated measures analysis of variance (ANOVA) was used for analysis following an intention-to-treat approach. Results: Physical fitness including flexibility, abdominal muscles strength, body balance and cardiorespiratory endurance (VO2max) were significantly improved in the intervention group compared to the control group. The intervention group also had significantly increased energy expenditure, light PA, walking time, moderate PA, and moderate-to-vigorous PA, while had decreased sedentary time and elevator use. They also had improved a range of dietary practices by increasing consumption of breakfast, dairy, and water. Furthermore, their health knowledge of each topic was significantly increased. Weight measurements did not show any significant change. Tobacco smoking and substance abuse were scarcely reported which could be due to cultural sensitivity. Conclusion: A health promotion intervention in school was successful in increasing physical activity and physical fitness, and improving dietary practices in adolescent females in Kuwait. Thus, such interventions are promising and should be invested in and expanded in this population. These interventions should also be supported by socio-environmental changes including families, youth organisations, and health policies.