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Objective: This research discovers patients’ experiences of the new and traditional routes of care and reveals the advantages and disadvantages of each within a chosen locality. It informs how a community service is delivering the new health agenda and most importantly how the patients feel and perceive their journeys through community-based care and hospital-based care. Therefore, its findings are crucial as feedback on how successful health plans have been to move more care to the community. It will reveal the Early Response team’s processes to ensure the service is fully utilised in intermediate care and give a better understanding about which patients are suitable for the home service. DESIGN – This qualitative research takes the form of multiple case studies encompassing semi-structured interviews to encourage discussion on the topic of care journeys. Participant information sheets and consent forms were used. The anonymity of the participant was upheld by using a pseudonym to refer to their contribution. All patients gave consent for the staff member who assessed them to be interviewed giving a total of three case study sources of the home patient, the hospital patient and the staff member as the units of measurement. Themes were searched for in the coding process derived from Kolcaba’s (2010) comfort theory and the bio-psycho-social model (Engel, 1977). These were physical, psychological, social and environmental along with two themes derived from the literature review of age discrimination and loneliness. Data generated helped ascertain the success of an alternative type of care service and formulated recommendations for practice. Setting: The patient interviews took place at the patients’ home so that they had time to experience their care pathway. Staff interviews took place in a quiet room at their place of work. Flexibility was offered regarding location, time of day and if the patients wished relatives to be present. Participants: 10 patients and 10 staff were interviewed totalling 20 participant interviews. The patient group was split into 5 patients who attended A & E and received their subsequent care in hospital and 5 patients who attended A & E and 4 were able to receive their subsequent care at home with the Early Response Service. The patients from each group were matched on the basis of same/similar injury. Each staff member who assessed the patients was matched to their patient, giving a multiple case study of the home and hospital patient and two staff members. The age range of patient participants was 72-89 years old and the staff participants 39-58 years old. There were 8 females and 2 males in the patient group and 9 females and 1 male in the staff group. Results: Data were analysed using the six theme headings and by searching through data for specific reference to answering the research questions. Key words found were burden, coping, independence or dependence, recovery, pain, equipment, finance, frailty and disorientation. Comfort took the form of pain relief, carer assistance and reassurance, not feeling a burden and having needs met in a timely fashion. Discomfort took the form of pain, cold, hunger, loneliness, finances, disorientation and needing more flexibility in carer calls. Tabular analysis revealed all hospital admissions were necessary and the reasons for admission were more serious or required medical/surgical intervention compared to the home care group. Positive home patient comments included being able to have care at home with less disruption to patients’ social networks and positive hospital patient comments included being able to receive maximum assistance over a 24 hour period as they felt they could not have coped at home. Results in relation to ageing theory, age discrimination and loneliness are discussed and interestingly care at home can be interpreted as positive discrimination of the older person by offering an alternative care option. Both hospital and home patients were satisfied with the care they received on the whole. Conclusion: The Early Response Service are correctly identifying the most suitable patients to receive care at home. An improvement in staff resources or skills such as intravenous drug administration would widen their referral criteria to be able to offer their service to more patients. There is still work to be done in respect of pulling patients out of hospital who are deemed medically stable, but are waiting for social care packages.

Midwifery practice in Ireland has emerged from a system of care dominated by the biomedical model of childbirth. The aim of this study was to explore the experiences of labour ward midwives who are potentially complicit with this approach. This study reveals how midwives’ environment impacts on their construction of childbirth. The opening of a large new maternity hospital afforded the opportunity to see if the move to this setting would influence midwifery practice. A hermeneutic phenomenological approach was used based on the work of Heidegger and Gadamer. The study was undertaken in two phases, the first involved interviewing six labour ward midwives working in a busy obstetric led labour ward which was due to close. The findings revealed that midwives complied with the norms for the unit and did not take responsibility for the biomedical approach to care. The second phase was undertaken twelve months after the opening of the hospital which was an amalgamation of three maternity units. Seventeen midwives were interviewed for this phase of the study. The move to the larger unit revealed a paradox for midwifery autonomy and enabled midwives to practice in new ways. The maternity service was delivered through a system that values detachment and an attempt at equal (not individualised) care under conditions of limited resources and constraints. This had resonance with Lipsky’s and Foucault’s work. A contrasting situation occurred within the individual labour rooms as the midwives worked in relative isolation, away from the general activity of the unit. This phase of data was framed in terms of Merleau-Ponty’s four existentials. Midwives had opportunities to enact ‘real midwifery’ and normalise birth for women using a range of strategies rather than resorting to interventionist therapies. Midwives shared in the joy of achievement when positive births occurred. The paradox of this mega maternity unit enabled authentic midwifery to emerge. The study provides an insight into the experience of labour ward midwives and how midwifery identities are revealed by the narratives they relate. It also highlights the complexity of contemporary maternity care in large centralised maternity units.

Background: Literature indicates underutilization of Palliative Care Services in the UK, with possible inequalities of access. These trends in underutilization are seen in Adult-Palliative Day-Care (APDC), a Specialist Palliative Care Service delivered in the outpatient setting. However, gaps in knowledge remain regarding if underutilization in APDC is real, and the identity and nature of the factors which determine access. Aim: The overall research question was “What are the factors which act to determine access to APDC?”. Five sub-questions for exploration in the context of access were formulated relating to the: perceived health care needs of users; the benefits of using APDC, and understandings of the role of APDC as a palliative care service. Methods: The study site was a cancer network in the Midlands of England which covered rural and urban areas. It contained 5 APDC units, 3 Primary Care Trusts, and 3 Acute Care Trusts. Fifty semistructured in-depth interviews were conducted with: 19 providers of APDC; 13 health professional referrers; 11 palliative care patients who had used the service; and 7 of their carers. The reasons for non-attendance for 149 patients who were referred to day-care but did not attend were also analysed. Thematic analysis with constant comparison and content analysis were used to analyse transcripts and document data respectively. Results: Eighteen determinants of access were identified arising out of the characteristics of the: potential service user (2), the health service or organization (9), and from interactions between potential service users, the family, the wider society, and the health service (7). The study found that utilization measures in APDC may not be accurately representing service use, as APDC units maybe functioning at their maximum capacity while current calculation methods report underutilization. Conclusion: New insights into accessing APDC are presented which and may have applications for future policy and research.

General practice has undergone considerable change in the last two decades. New roles for nurses working in general practice have extended to include tasks that were previously delivered by general practitioners, in particular chronic disease management, and the development of new, advanced roles such as independent nurse prescribing. There have been few research studies investigating the impact of these changes, especially after the introduction of the new General Medical Services contract in April 2004. The overall aim of the work presented in this thesis was to examine the emerging roles of practice nurses, the forces influencing that development, and the effects of these changes on doctor-nurse skill mix in general practice within NHS Scotland. The work employed a mixed methods approach, with three inter-linked studies. The first study was a quantitative, desk-based analysis of workload and clinical activities of doctors and nurses working in 37 practices across Scotland for the year 2002. The second study was a postal questionnaire to all practice nurses working within NHS Greater Glasgow (n=329), conducted in autumn 2005 and achieving a 61% response rate. The third study was a qualitative study, consisting of eighteen interviews with a doctor and nurse inform each of nine general practices. The interviews were conducted between January and July 2006 and practices were selected according to the number of partners and the deprivation status of the practice population. Analysis of workload data showed that practice nurses and general practitioners dealt with 27.5% and 72.5% of total face-to-face encounters, respectively. Many of the encounters with nurses involved chronic disease management, with 20% of such encounters appearing similar in content to the work of GPs. The postal survey found that one third of practice nurses were aged over 50, and will be approaching retirement within 10 years. The majority worked in small teams of nurses, although 31% worked alone. This may have contributed to the finding that 52% (n=103) reported feeling isolated in their workplace. Many had attended CPD training on chronic conditions, but identified minor illness treatment as an area for future training. The qualitative study showed that the Quality and Outcomes Framework of the 2004 contract had been a key driver of changes in general practice service delivery. This has led to an increasing shift in routine care from doctors to nurses. As new roles for practice nurses have evolved, GPs have been able to focus on treating complex morbidities that need medical diagnosis and intervention. The incentivised targets of the new contract have made chronic disease management a predominant activity for practice nurses, with treatment room and non-incentivised activities featuring less and increasingly being provided by new, lower grade nurses or nurse replacements such as Health Care Support Workers (HCSW). There was no consensus between interview participants in terms of the most appropriate use of doctor-nurse skill mix in general practice. Nor did they agree on the merit of advanced roles for practice nurses. However, respondents did emphasise that nurses who wanted to have an independent/advanced role in the practice would need to combine three competencies (independent nurse prescribing, triaging, and minor illness treatment). Most practice nurses interviewed were concerned with obtaining a fair financial return to match their increasing responsibilities, especially after the introduction of the nGMS contract. GPs, however, tended to believe that nurses were appropriately remunerated for the level of responsibility they had within the practice. The continuing role of the GP as the employer of practice nurses was problematic for some nurses and many felt there would be advantages to being employed on Agenda for Change terms and conditions. However, the majority of nurses interviewed preferred being employed by a GP rather than the Health Board. There was little support amongst either nurses or GPs for the notion of nurse partners within practices. Overall, these studies provide lessons which will be of value in planning the future training and development of practice nurses. It suggests that practice nurses should obtain proper training and support in order to meet their individual needs and to carry out new responsibilities and roles. In addition, the impending shortage of practice nurses due to retirement, lack of retention and potential recruitment difficulties needs to be addressed urgently at the level of primary care policy and manpower planning.

This study explored the experience of patients with generalized anxiety disorder (GAD) undertaking a six week intervention of a Zen meditation programme in Taiwan. Mix-methods were used including the Revised State and Trait Anxiety Inventory (RSTAI), repeated focus groups, individual interviews, diaries and field notes. Heidegger’s interpretative phenomenology was adopted as a theoretical framework. Two groups of 9 and 12 patients (n=21) participated in the study. Three themes emerged from repeated focus groups: First ‘Expectation of Zen meditation regarding GAD symptoms included sub themes of ‘ambivalence towards meditation’, ‘crave a good sleep’, ‘stop thinking’ and ‘regain memory and concentration’. The second theme, ‘The process of Zen meditation’ included the sub themes of ‘struggling to reach a state of calm’, ‘signs of improvement’ and ‘an individual process’. The last theme, ‘The cultural beliefs regarding Zen meditation in Taiwan’ involved the ‘spiritual influence’ of Zen meditation practice. Four themes emerged from individual interviews. Firstly, ‘Separation’ referred to the issues that participants faced in dealing with the termination of the programme, including ‘concern about other participants’ and ‘examining the relationship between Zen meditation and self’. The second theme ‘Body experience of Zen meditation practice’ incorporated ‘body awareness’ and ‘preparing to practise Zen meditation’. The third theme, ‘States of mind while meditating’ consisted of ‘the state of engagement with real life’, ‘the state of detachment from real life’ and ‘the state of calm’. Lastly, ‘Benefits of Zen meditation practice’ incorporated the categories ‘less pressure with daily life’ and ‘more acceptance of being a GAD patient’. The RSTAI was administrated at baseline and post intervention and also at the two week follow-up of the Zen meditation programme. Neither the Trait Anxiety Score nor the State Anxiety Score showed significant differences between Groups 1 and 2 at baseline. This allowed the RSTAI data from the 2 groups to be merged.The results of 95% confidence interval for differences of both groups showed a significant improvement in the Trait Anxiety Score over time but not the State Anxiety Score. This study contributes to the existing body of knowledge and associated literature regarding Zen meditation and GAD in three ways. Firstly, the findings confirmed that the essential or authentic traditional qualities of meditation should be addressed in meditation study. Secondly, the meaning of Zen meditation for the groups of GAD patients was revealed in the context of Taiwan society. How their lived experience of GAD shaped their understanding of Zen meditation was interpreted. Thirdly, a comprehensive understanding of Zen meditation is reported. The findings (including themes, i.e. diverse Zen meditation processes, body experiences, concepts of obstacles and spiritual influence) add to the current knowledge by providing insight derived from participants’ lived experiences.

Aim: Investigated the use of granulated sugar in the management of sloughy, necrotic and infected exuding wounds. Method: The investigation followed the Medical Research Council (MRC, 2007) framework for investigation of complex interventions. Pre-clinical: The study was registered with MHRA, followed by development and design of the mode of sugar delivery to patient use. Evidence review: A systematic review and meta-analysis concluded that there was no existing good quality evidence to support the routine use of sugar dressings. Phase I: Laboratory studies found that all three sugars showed relatively equal activity against all the bacteria tested although Demerara sugar was slightly less active. Phase II: A feasibility study of 22 patients concluded that both insulin and non-insulin treated diabetic patients can be treated with sugar dressing without affecting their blood sugar levels. Phase III: A randomised controlled trial failed to recruit the intended numbers and final analysis was carried out on 22 patients randomised to sugar and 19 randomised to usual care. 19 (86%) achieved debridement at 4 weeks in the sugar group compared to 6 (32%) standard care group (Fisher’s exact test: p<0.001). Overall conclusion: Sugar has an effect on micro-organisms and can be used in modern hospitals and community settings.

Aim of the thesis: To report on a study to describe and explain the contribution of registered nurses’ and care assistants’ to hospitalised patients’ mobility rehabilitation. Background: Studies internationally have shown that older adults often experience a decrease in their ability to mobilise during and after hospitalisation. Rehabilitation nursing interventions could be important in maximising the functional abilities of this population. Methods: A grounded theory approach structured data collection and analysis. Data were derived from three hospital settings (general rehabilitation, spinal injuries and stroke rehabilitation) and included 39 staff interviews and 61 hours of observation. Findings: Mobility rehabilitation is an ‘embedded activity’ and is achieved indirectly when nurses and care assistants transfer patients safely from one place to another. These events are described as ‘A to B transfers’. Practitioners perceive distinct differences in the process and purpose of ‘A to B’ transfers in comparison to ‘therapeutic handling’ activities undertaken by physiotherapists and occupational therapists. The core category for the grounded theory (Care to keep safe: Safe to care) is used to explain the findings. Conclusion: Theoretically, the nursing team could implement more structured intentional strategies’ to promote patients’ mobility rehabilitation. However, teamworking arrangements and work environments do not facilitate this.

In 1975, the medical staff at Glasgow's Western Infirmary suggested a study of patients making frequent and inappropriate use of the hospital IS acute receiving area. The staff claimed that these patients seldom had acute medical problems; they wasted the doctors I time; and consumed a substantial amount of hospital resources. The staff wondered what prompted the behaviour of these patients and whether they could be better managed in the future. In order to identify the frequent and inappropriate users of the acute receiving area, we reviewed the past acute attendances of the 3,284 patients in our patient sample. As we had no objective measures of inappropriate patient behaviour, we used the frequency of presentation as our sole selection criterion. knowinq that any frequent and inappropriate users would thereby be included. After samplinq the patient records. we defined frequent attendance as six or more acute attendances between 1st January 1970 - 31st July 1975, a 5 year 7 month study period. We found 150 (5%) of the 3,284 patients studied had been frequent attenders. We looked for ways to identify the frequent attenders at presentation but found no significant difference in age. sex. or presenting complaint between the frequent attenders and the 3.284 patients sampled. We then used these characteristics (age. sex, and presenting complaint) to select matched controls from the patient sample for each of the 120 frequent attenders who proved available for interview. We found inappropriate use of the acute receiving area mentioned in all but two of the 120 frequent attender records and 68% of the frequent attenders' acute presentations were attributed to inappropriate patient behaviour. While few (12%) frequent attenders were diagnosed as having greater medical problems than their matched controls, psychological problems were diagnosed in 77% of the frequent attenders in contrast to only 22% of the controls. The patients· answers at interview showed frequent attendance strongly associated with a number of background variables, with no single variable proving pathognomonic of frequent attenders. We found that, on average, the frequent attenders had greater health, housing, and employment problems, greater difficulties in relating to others, and were more accident-prone than their matched controls. We found most of the acute receiving area costs to be fixed costs and thought little would have been saved had the frequent attenders not presented. We thought the amount of hospital resources consumed by the frequent attenders was too small to. adversely affect other patients. Our study showed that a small number of frequent and inappropriate users of the acute receiving area indeed existed at the Western Infirmary. However, we thought that little could be done either to alter the social and psychological factors we found associated with frequent attendance or to prevent future acute attendances by these patients. At a hospital level, we thought the costs and risks involved in excluding the frequent attenders were outweighed by the benefits of simply treating these patients. At a community level, we thought that seeing the frequent attenders on demand in the acute receiving area was an efficient and relatively inexpensive way of supporting and maintaining these patients in the community.

Background: The social consequences of having a stroke can be severe, with social isolation a reported problem. It is little explored, however, what factors predict who will feel well supported and retain a strong social network after a stroke, nor is it well understood why friendships and other social contacts are lost. Aims: This thesis explored: 1) how social support and social network change over time following a stroke, and whether this is different for those with aphasia; 2) what factors predict perceived social support and social network six months post stroke; 3) why people lose contact with friends, and whether there are any protective factors; 4) how the changing dynamics within the family unit are perceived by the stroke survivor. Design and setting: Repeated measures cohort study. Participants were recruited from two acute stroke units and assessed at two weeks (baseline), three months and six months post stroke. A subset of participants was selected for in-depth qualitative interviews 8 – 15 months post stroke. Measures and methods: Stroke Social Network Scale; MOS Social Support Survey; General Health Questionnaire; National Institute of Health Stroke Scale; Frenchay Aphasia Screening Test; Frenchay Activities Index; and the Barthel Index. Multiple regression, ANOVA, correlation and t-tests were used as appropriate. Results: 87 participants were recruited of whom 71 were followed up at six months. At six months, 56% of participants were male, 16% had aphasia, and the average age was 69 years old. 29 participants took part in qualitative interviews. Perceived social support at six months was not significantly different from pre-morbid levels; social network, however, did significantly reduce (p = .001). Those with aphasia had comparable levels of perceived social support but significantly reduced social networks (p < .05) compared to those without aphasia. Concurrent predictors of perceived social support at six months were: a person’s social network, their marital status, and their level of psychological distress (adjusted R2 = .37). There was only one baseline predictor of social support at six months: perceived social support prior to the stroke (adjusted R2 = .43). Concurrent predictors of social network at six months were: perceived social support, ethnic background, aphasia and extended activities of daily living (adjusted R2 = .42). There were two baseline predictors: pre-morbid social network and aphasia (adjusted R2 = .60). There was a significant reduction in the Friends factor of the social network measure (p < .001). The main reasons for losing friends were: changing social desires especially a sense that many participants were ‘closing in’ on themselves; aphasia; loss of shared activities; reduced energy levels; physical disability; environmental barriers; and unhelpful responses of others. Family were generally robust members of the social network post stroke. The spouse was the main provider of all support functions. Nonetheless, beneath the apparent stability of the quantitative data there were changes in how family relationships functioned, including some distressing role shifts, for example, receiving rather than providing support. Conclusion: Contact with family and perceived social support remained stable post stroke. In contrast, a person’s social network, in particular contact with friends, was found to reduce, especially for those with aphasia. Indeed, aphasia was the only stroke-related factor at the time of the stroke that predicted social network six months later. Intervention aimed at addressing social isolation may be most effective if it takes into account the multiple reasons for friendship loss, including new language and physical disabilities, as well as changing social desires.