Over the past 30 years, Senior and Advanced Nurse Practitioners (SNPs/ANPs) have been introduced into the healthcare arena across the world. The international literature reports such roles have created tensions within healthcare systems (Smith 2000; Tye & Ross 2000; Scholes & Vaughan 2002). However, over the past three decades the root causes of such tensions remain still to be addressed. The literature reports the consistent entrenched reluctance to collaboratively engage with SNP/ANP roles (Cummings et al. 2003; Reay et al. 2003; Davies 2006). This led to the aims of my Constructivist Grounded Theory (CGT) study, which were to discover why there continues to be tensions surrounding Senior and Advanced Nurse Practitioner roles in healthcare, in addition to attempting to generate a substantive theory to provide a foundation in which a hypothesis could be tested across a wider arena. Arising from these aims were three research questions which were explored in three phases. The first research question, posed in phase 1, was ‘where are tensions created by Senior and Advanced Practitioner roles from a service user and healthcare team perspective?' This led to in-depth interviews taking place with service users (n=12) and members of the healthcare team (n=18). Theoretical sampling consisted of medical staff (n=9), nursing staff (n=7) and Allied Health Professionals (n=2). Data were considered saturated when no new data could be identified and the main categories with focused codes were coherent. The second research question, posed in phase 2 of my study, was ‘where do tensions remain apparent in service and what meanings and actions are attributed to them?' The method of Grounded Theory Ethnography was employed, which gave priority to interactions rather than the setting. This method consisted of a 3 stepped approach, employing participative observation and individual interviews. In total, 13 periods of observation were undertaken, which equated to 64 hours of observation within different sites. The emergent categories from this phase built upon the categories from phase 1. In phase 3 the research question posed was ‘what are the interpretations of Senior and Advanced Nurse Practitioners on interactions with the healthcare team and service users?' Six focus groups and one paired interview enabled the development of the core category “Status Games”. This subsumed the main categories from each phase and incorporated common themes and patterns across all data. This core category was further verified with five individual interviews and no new properties emerged. This core category reflected the data across all phases effectively. Interpretative theorising incorporated advanced memos across all 3 phases of my study and enabled the development of a substantive theory. Social psychological game theory and underpinning script theory, which is part of the Transactional Analysis Paradigm, provided the theoretical lens to interpret what was grounded in the data. This led to the development of two new concepts, the first was status games which incorporated game analysis and highlighted ulterior transactions which have not been previously reported in the literature. The second was the professional script concept, which it is theorised underpins status games. This is also new and has not been conceptualised in the Transactional Analysis or healthcare literature. This theoretical framework illustrated that status games which fulfil professional script are being played out with awareness. It is proposed that by recognising these concepts, this will reduce tensions with SNP/ANP roles and lead to improved patient-centred care. As Vandra (2009) reports by recognising the processes and actions of communication it is possible to bring ulterior transactions into full awareness and prevent games, thus problems with communication. This led to the development of the substantive theory in this study which is: ‘The tensions generated by SNP/ANP roles stem from playing status games to fulfil professional script which requires to be recognised and acknowledged by the healthcare team in order to change the status quo and culture'. Whilst social psychological game and script theories can provide an underpinning understanding of social games and life scripts for individuals, the status game concept which emerged from my study expands our knowledge and provides a unique understanding surrounding the impact of professional script in healthcare organisations. It is hypothesised that this script has led to status games, which is central to the tensions surrounding SNP/ANP roles.

The present research used van Manen's application of hermeneutic phenomenology as philosophy and method to explore stroke rehabilitation experience across two different settings, i.e. (i) a conventional setting (National Health Service or NHS stroke unit) and (ii) an unconventional setting (Conductive Education or CE). Interviews, observations and reflective diaries were used to collect data on 24 volunteering stroke patients' experiences. High levels of dis empowerment and negative images of self as well as the nature of motivation were indicated to be thematic of stroke rehabilitation experience in the stroke unit. In the CE setting stroke rehabilitation experience was characterised by increased selfconfidence, unconditional positive regard from conductors, challenging activities and body-half integration. A juxtaposition of stroke rehabilitation experience in the CE setting with stroke rehabilitation experience in the NHS stroke unit brought to light an important difference between the physical body-split caused by stroke, and a much wider and deeper disintegration of being. The juxtaposition further indicated that (i) the approach used in the NHS stroke unit is biomedical in spite of the presence of a multi-disciplinary team, and (ii) that the one adopted by CE is a person-centred approach characterised by holistic principles, with an overall focus on mobility. A reflective evaluation of this hermeneutic phenomenological study ensues, including a discussion on the difference between person-centredness and holism. The better understanding gained regarding stroke rehabilitation experience across the two settings was then used to make recommendations regarding what could constitute a holistic approach to stroke rehabilitation. Finally, the researcher's experience of 'being-immersed' in others' lived experiences was discussed in order to illustrate the holistic effect the research process had on the researcher's well-being, and the development of a tool which addresses researcher emotions holistically is also presented.

The employment of registered general nurses (RGNs) is underpinned by management’s need for economic utility in that the cost of salaries must be reconciled with the need to meet the demands inherent in service provision. Using grounded theory, interviews captured the experience of physically disabled RGNs, who use the phrase ‘physically disabled’ to describe themselves. Their collective experience was then compared with nondisabled RGNs working in the clinical areas of general medical wards, general surgical wards, and day case units, situated in three district general hospitals. Data collection was by partial participant observation, and interviews. The data revealed that both nurseinterviewee groups share an understanding of the meaning of health and illness. Both the physically disabled and non-disabled RGNs manipulate working time to take unauthorised breaks in order to ‘accommodate tiredness’ and ‘stamina lack’. ‘Accommodating need’ is the identified basic social process (BSP) and ‘pacing’ is the identified core category. RGNs distinguish between using a ‘public’ voice and a ‘private’ voice. In respect of a physically disabled RGN ‘doing nursing’, the data uncovered stigma relating to a spoiled identity. Theoretical sampling interviews with senior nurse managers, occupational health doctors, and trade union officials (termed ‘elite groups’), reflected the data findings of both the physically disabled, and non-disabled RGNs, in identifying the factors limiting the employability of physically disabled RGNs. Moreover, data from the elite group interviews revealed the importance of economic utility, in that management has to take account of diminishing returns. This is the crux of the employment issue. ‘Maintaining organisational pace’ is the generated grounded theory, and was confirmed by aligning data to the established literature on Labour Process Theory (LPT) in a supplementary theoretical sensitivity validation process.

This thesis explores how patients and practice nurses negotiate and manage decisionmaking involving risks associated with type 2 diabetes. The location of the study was general practice as this reflects the significant shift of diabetes management for people with type 2 diabetes over the last decade. Purpose of the study To improve understanding of what is effective when communicating about risks to people with diabetes and how people with diabetes use information on risk to make decisions about how they manage their diabetes. Overview of study design A qualitative approach, based on case studies involving a patient with diabetes and a practice nurse who was their main diabetes care provider, was undertaken in three local general practices. Grounded theory methodology was used to investigate the perspectives of healthcare professionals and patients managing risk of diabetes complications. Data collection involved audio recording or observing a consultation between a person with diabetes and their practice nurse, followed by individual interviews with each. The follow-up interviews were lightly structured around a topic list, which was adapted to pick up issues identified from the consultation. Subsequent interviews were informed by theoretical sampling consistent with the grounded theory method. Data was analysed through cycles of data collection, coding and constant comparative analysis with the development of categories and the final core category: ‘Responding according to risk perception’. Findings: What this study contributes to understanding risk communication and how risk is managed: • Patients live with uncertainty which impacts on their behaviour and how they manage risk; • Diabetes creates a social risk for patients which has to be managed in their daily lives; • Practice nurses balance the tensions of formal and informal risk management in order to meet professional and organisational requirements as well as the expectations of patients; • Effective risk communication may be enhanced by the quality of the nurse-patient relationship, the use of visual metaphors and anecdotes involving ‘similar’ others.

Within secondary care hospital settings, acutely ill patients are exposed to the unnecessary risk of the adverse consequences and increased mortality that arise from suboptimal care. A causative factor of suboptimal care is the level of competence of practitioners caring for the acutely ill patient in their failure predominantly, to monitor, recognise or respond appropriately to the deteriorating patient. In partnership with local healthcare organisations, the acute illness course, on which this study was based, was conceived and implemented. The aim of the course was to provide an academic and clinical experience that focused on the development of skills and competence of post-registration practitioners within non-critical care settings. The first cohort commenced their course in 2006. This study investigated the development of this experience, focussing on students’ skills and competence following their exposure to a variety of teaching, learning and assessment strategies that had been employed. Competence is one of the most commonly used words in healthcare education yet it is a nebulous concept that is defined in diverse ways by different people. The concept of competence provided the theoretical framework that was analysed and applied within the field of acute care. An educational evaluation using a case study approach was used employing interviews for data collection purposes. The case study examined the many variables of interest within the student experience while maintaining a continuous interaction and dialogue between the theoretical and conceptual dimensions that were being studied. This inquiry opened by interviewing former students of the acute illness course. The aspects that were explored included, students’ characteristics, motivations and perceptions of the teaching, learning and assessment methods they had encountered. Of particular interest was the influence of these on the students’ development in clinical practice. Triangulation was adopted through interview data derived from both the former students and their managers. The study critically analysed the principle dynamics that influenced students learning in academic and practice settings. The findings demonstrated the intricate synergies that comprised this exercise in professional development. Motivation, emotional responses and performance were often influenced by the experience. The eclectic mix of learning methods that were used were thought beneficial by the study participants, who found that both the theoretical and the clinically related content of the course to be entirely relevant to their clinical practice. The study established that choice, facilitation and feedback through mixed learning and assessment methods leads to confidence and empowerment that positively influence registered nurses’ competence in clinical practice. It concluded that in this case, practitioners’ continuing professional development was influenced by interlocking concepts that supported the acquisition and maintenance of both their confidence and competence and as a consequence, stood to improve the care of acutely ill patients.

Aim of the Study: Personal Tutoring is a scholastic mechanism to aid and support students while on a demanding academic and clinically orientated pre-registration nursing programme. Personal Tutoring is widely used in nurse education programmes, although it is often poorly structured with a minimal evidence base and rarely evaluated. The increased numbers of student nurses has seen the role of the Personal Tutor as an intrinsic factor towards a positive student experience. Attrition is an important consideration, but this study aimed to enhance the staff and student roles through tutoring. Methods: this study, influenced by ethnography, adopted an action research methodology as it encapsulated a constant problem-solving technique. This involved the exploration of academic staff and student perceptions of a Personal Tutor's role within a School of Nursing and Midwifery. Staff and students contributed to semi-structured interviews after a series of focus groups. The focus group discussions utilised the nominal group technique to rank the key points of the posed questions. These priorities were the basis of five staff and five student follow-up semi-structured interviews; the transcripts were manually analysed for trends and complemented with the use of the computer software NVivo 7. This resulted in the development and implementation of School Personal Tutoring Guidelines based on 'good practice', along with supporting evidence from published research. A follow up focus group and questionnaire evaluated the staff's and students' experience of the guidelines, along with a more detailed analysis of two case studies using appreciative inquiry. Findings: the staff and student focus groups both agreed on areas of good and poor practice in relation to Personal Tutoring; there was also clear agreement about what did and did not contribute towards a supportive Personal Tutor commitment. The Personal Tutoring guidelines were formulated around eight key and shared areas of responsibility, which was a shift from previous approaches. The guidelines were implemented for staff and students through formal mechanisms and the Personal Tutor relationship became a central instrument for existing and future curriculum development and teaching and learning strategies. The follow-up evaluation continued to illustrate variable commitment from both staff and students towards Personal Tutoring, although the majority of the data indicated a positive influence on staff and student experience. Conclusions: the established guidelines form a standardised Personal Tutoring system based on academic staff and student perceptions of the tutoring role. This has subsequently been disseminated to all areas of the faculty, therefore utilising the cyclical ethos of action learning. Kolb's (1984) experiential learning cycle is used to illustrate the originality of this work and demonstrates how it has added to the existing body of knowledge on Personal Tutoring.

Introduction: There is a scarcity of research examining spirituality and spiritual dimensions of Advanced Nurse Practitioner practice. This thesis explores the findings of a hermeneutic enquiry into the spiritual dimensions of Advanced Nurse Practitioner consultations in Primary Care through the lens of Availability and Vulnerability. The findings include Advanced Nurse Practitioners’ understandings and conceptualisation of spirituality, the place of spirituality in practice and some of the concerns related to integration in practice. The participants’ interviews explored their own personal and professional experiences which added to their conceptualisation of spirituality. The lens of Availability and Vulnerability (A&V) was used intentionally and openly to explore, in depth, spiritual dimension of practice with the participants. The utility and effectiveness of the concepts of A&V in this context was explored. Methods/Methodology: A hermeneutic phenomenological enquiry was chosen to explore spirituality through the lived experiences of the Advanced Nurse Practitioners (ANPs). Eight participants were interviewed face to face during 2 in-depth interviews spaced 18 months apart. The concepts of A&V were introduced to the participants before the second interviews. The lens of A&V was utilised within these interviews to discover whether or not these concepts were helpful for operationalising spirituality in practice. The prolonged engagement allowed dialogue to occur between the researcher and participants allowing data to be captured which provided a thick description of the phenomenon of spirituality. A thematic analysis was chosen to interpret the data in order to enable a deeper understanding of the spiritual dimensions of ANP consultations to be gained. Findings The participants recognised that spirituality can be difficult to conceptualise and operationalise in practice. However, many of the participants were able to articulate the meaning of spirituality for themselves and gave examples of when they had witnessed a spiritual dimension occurring in practice. Particular themes were expressed in the interviews in relationship to spirituality. These included the context for spirituality to be integrated into care, the emotional engagement needed and the emotional impact on the ANP and the patient. Having introduced the concepts of A&V to the participants, after deep exploration, they recognised and identified that A&V were concepts which could be a useful lens for understanding spirituality in ANP consultations. Conclusion This study has uncovered new knowledge and understanding in the realm of spirituality in ANP consultations in Primary Care. The conceptual understanding of spirituality and the framework of Availability and Vulnerability provides a new approach to spirituality within ANP consultations in Primary Care.

This qualitative study takes an interpretative phenomenological approach to understand the experience of whiplash injury from the different perspectives of patient and doctor. This was carried out in order to identify what psycho-social consequences might be experienced by patients as a result of that injury and to identify any implications for healthcare provision. The research was conducted in two phases. During Phase One, eight patients were recruited through GP practices using a combined approach of retrospective and prospective sampling. Three semi-structured interviews and one telephone interview were carried out with each participant over a twelve month period. In keeping with phenomenological methodology, data were analysed using Template Analysis (King, 2004) and a set of themes relating to healthcare experience were identified: „embodiment‟ „experience of pain‟ „disruption to lifestyle‟, „making sense‟, „patient as expert‟ and „whiplash: a minor injury?‟. During Phase Two, one semi-structured interview was carried out with eight doctors who worked in either the primary or secondary care settings. Data were analysed using Template Analysis and a set of themes relating to their experiences of treating patients was identified: „expectations regarding what patients will experience‟, „what patients do about their whiplash injury‟, „what doctors do‟ and „blame if things go wrong‟. These findings show how the patient participants‟ physical and psychological experiences of their malfunctioning body had consequences for maintaining their sense of self and their ability to carry out their normal everyday activities at home and work. The doctors‟ own expectations of treating patients with whiplash injury and whether or not they trust the patients‟ account have illustrated three approaches: dismissive, reactive or proactive that have different implications for patients‟ experiences of healthcare. The study shows how the notion of „compensation‟ is implicated in whether or not the doctor feels able to trust the patient‟s account. The implications of these findings can be seen in terms of methodological focus, general practice and policy formulation. Methodologically interpretative phenomenology provides a theoretical foundation that is, at the very least, equal to and able to challenge more „traditional scientific foundations‟ through its focus on meaning. In terms of practice and policy formulation, the findings have provided a unique insight that might prove to be beneficial for understanding the health care experience and assist in the provision of guidelines aimed at the treatment of whiplash injury. Indeed it is advocated that doctors adopt a subjective approach and that this is taken into account in training.

Background: In modern neurological physiotherapy practice, a patient’s neuroplasticity is harnessed, teaching them to develop motor control at ‘impairment’ level. Consequently, the patient relearns ‘normal’ movement, which in turn enables them to gain more efficient function and independence that has significant impact on their ‘life’. However, there are no outcome measures that capture the patient’s quality of movement, or the specific effects of physiotherapy intervention. Such an outcome measure, the Leeds Movement Performance Index, was developed to fill this gap. It was hypothesised to be a valid, reliable and clinically useful tool. Methods: A multi-centre, three-part, mixed-methods study was undertaken with three groups of neurological physiotherapists (n=34) and patients with neurological diagnoses (n=42). A range of quantitative and qualitative methods were used: Consensus methods to develop the new outcome measure; psychometric tests to examine reliability and validity against existing outcome measures in the field; focus groups, face-to-face interviews and reflective writing to further explore clinical utility. Results: The Leeds Movement Performance Index was shown to be a tool with strong measurement properties i.e.: internal consistency (Chronbach’s, overall scale=0.862), inter-rater reliability (ICC=0.959); test-re-test reliability (rho=0.792); and criterion validity compared with the Berg Balance Scale (rho=0.468, SD±2). Thematic analysis demonstrated robust content validity and clinical utility. Furthermore, it un-expectedly revealed that the Leeds Movement Performance Index also supported fundamental aspects of neurological physiotherapy clinical practice, including assessment, analysis and clinical reasoning, and potential usefulness as an education aid. Conclusion: The Leeds Movement Performance Index makes an important and novel contribution to the field of neurological physiotherapy, both clinically and within research practice. It is the first outcome measure to conceptually map the nature and definition of quality of movement for patients with motor impairment, and it captures the impact of neurological physiotherapy intervention more responsively compared with other outcome measures routinely used within the field.

Objective: Physical activity has been shown to improve sleep, fatigue and mood among breast cancer patients during treatment. However, few studies have focused on assessing the effect of activity on these symptoms after treatment is complete. Using a correlational design, this study aimed to explore associations between physical activity, sleep, fatigue and mood in women who had completed treatment for breast cancer and to evaluate the reliability and validity of the short-version International Physical Activity Questionnaire. Methods: Twenty-eight women (aged 43 to 75 years) with stage I and II breast cancer were recruited at 6-months post-diagnosis and after completion of active treatment. Respondents completed measures of activity, sleep, fatigue, depression and anxiety. Six participants also undertook actigraphic monitoring to obtain objective activity levels. Results: Descriptive analyses suggest the sample was relatively active with 50% of participants engaging in moderate-intensity activities. Despite this, however, only 18% were sufficiently active to meet national guidelines. No significant relationships were found between total physical activity, sleep, fatigue or depression, whereas, anxiety and activity were significantly correlated. Reliability of the IPAQ was low, however, comparison with objective actigraphy data suggests high criterion validity. Conclusion: These findings have implications for designing interventions to reduce anxiety among breast cancer patients returning to physical activity after treatment. However, the choice of assessment instrument may have a significant impact on research results.