The Mental Capacity Act (2005) (MCA) is part of the legislative framework of the NHS. Small scale studies in a range of health settings have shown that the understanding and use of the MCA (2005) varies considerably in different services and across staff of differing occupations and grades. The experiences of individual staff in using the MCA has received little attention. This grounded theory study aimed to explain how staff working with people with a learning disability (PWLD) make sense of and use the MCA, whilst also exploring the factors that influence applying the MCA in clinical practice. This study involved 11 healthcare staff from a specialist learning disability service that had used the MCA in the six months prior to their participation in the research. Staff interviews provided narratives about how they had used the MCA. A theoretical framework was developed from the analysis which underpinned three core conceptual categories. The first core category was that of ‘professional risk’ in which staff have awareness of a series of risks that pertain to themselves or the service user that could have negative professional or legal consequences. The second core category described ‘emotional risk’, which affected both the staff and service user. Staff appeared to experience those risks as feelings in the form of anxiety or concern. Both ‘professional risk’ and ‘emotional risk’ bring about ‘strategies’ which mediate the risk; allowing staff to justify and document their position, creating what feels like safe practice for both the staff and service user. Factors which facilitate the use of the Act are concerned not only with these risks but the significance of the decision that the service user has to make. The findings suggest that there is much uncertainty in the process of using the Act, some of which is due to the subjective nature of evidence gathering. The study suggests that peer support offers a range of factors important to education and development of experience in using the Act, along with helping staff cope with the outcome of decision making. The findings have clinical implications for those involved in managing difficult assessments and decision making, including how to gain an appropriate balance between risk and human rights against a backdrop of adversity that can be present for people with a learning disability. Further implications clinically and for future research, along with limitations of the study are also discussed.

Treatment and advice on amoebic dysentery from case studies onboard H.M.H.S. Lanfranc, May 1916.

The typical picture that is conjured up when one thinks of a nurse is that of a matronly figure, in a uniform and cap, sitting at the patient’s bedside administering care. Associated with this is the traditional view held by the public, in which nurses are beholden to doctors and dependent on them for instruction, and perform a generally subservient role. However, those who have had the misfortune to require treatment more recently will testify to a far different situation, in which nurses perform a more professional and clinically autonomous role, as well as having a caring and compassionate function. In fact, the picture that exists in most clinical environments is one in which nurses are recognised as knowledgeable and capable clinicians, and independent practitioners in their own right, rather than obedient medical handmaidens. The delivery of modern healthcare has also changed beyond recognition, with interventions that were once considered to be the domain of hospital practitioners now provided in a more liberated community-based system. Within this structure, the role of healthcare professionals has similarly been transformed, such that the ‘power’ has shifted away from doctors and towards non-medical clinicians. This has, in turn, resulted in non-medical practitioners, most notably nurses, having more authority, autonomy and responsibility for clinical decision-making, rendering them more equal in the clinical hierarchy and more evenly aligned as professionals. This thesis explores the range of traditional medical activities that are now performed by nurses who have expanded their practice in order to accommodate the additional responsibilities that this 'power' affords. In particular, it looks at those nurses who have advanced their practice such it constitutes a new clinical role and, in some cases, act as medical substitutes. With the further devolution of clinical tasks inevitable, and the creation of more clinical roles likely, this thesis looks at the regulatory framework that underpins advanced nursing practice. In particular, it questions whether the existing framework provides the regulatory safeguards that are required to ensure patient and public protection and asks whether an alternative approach, such as that which is provided by another professional regulator, may be more appropriate. In concluding, this thesis will assert that a compelling case for the statutory regulation of advanced nursing practice can be made, and will suggest a number of options regarding how this regulatory solution can be achieved.

Regular breastfeeding surveillance is essential to determine to what extent national breastfeeding targets are being met and how breastfeeding practices change over time. There have been irregular infant feeding studies or national surveys carried out in Kuwait so it is difficult to assess secular trends in breastfeeding practices. The objective of the Kuwait Infant Feeding Study (KIFS) was to identify the incidence and prevalence of breastfeeding up to 26 weeks postpartum among a population of women living in Kuwait and to identify the factors associated with the initiation and duration of breastfeeding. A sample of 373 women recruited shortly after delivery from four hospitals in Kuwait completed a structured, interviewer-administered questionnaire and follow-up telephone interview at 6, 12, 18 and 26 weeks postpartum. Multivariate logistic regression analysis was used to identify those factors independently associated with the initiation of breastfeeding and survival analysis was used to examine the duration of breastfeeding. In total, 92.5% of mothers initiated breastfeeding and at discharge from hospital the majority of mothers were partially breastfeeding (55%), with only 30% of mothers fully breastfeeding. Prelacteal feeding was the norm (81.8%) and less than 1 in 5 infants (18.2%) received colostrum as their first feed. Only 10.5% of infants had been exclusively breastfed prior to hospital discharge, the remainder of breastfed infants having received either prelacteal or supplementary infant formula feeds at some time during their hospital stay. At six months of age, 39% of mothers were still breastfeeding but none of the women were fully or exclusively breastfeeding. The median duration of any breastfeeding duration was 13.9 weeks. 2 Breastfeeding at discharge from hospital was independently positively associated with paternal support for breastfeeding and negatively associated with delivery by caesarean section and with the infant having spent time in the Special Care Nursery. Mothers originally from other Arab countries were more likely to initiate breastfeeding in hospital than Kuwaiti mothers. Women whose husbands worked in sales or clerical occupations and Kuwaiti national mothers were at higher risk of early breastfeeding termination. Women whose husband or own mother preferred breastfeeding, breastfed for longer than those women whose husbands or mothers preferred formula feeding or were ambivalent about how they fed the infant. Hospital-related factors including time of first feeds, type of first feed, age of introducing a pacifier and feeding on demand were significantly associated with breastfeeding duration. The results of this study indicate that while breastfeeding is almost universally initiated, very few women achieve the WHO recommendations of exclusive breastfeeding to 6 months of age. The reasons for the high use of prelacteal and supplementary formula feeding warrant further investigation. Data collected in this study will contribute to the limited breastfeeding surveillance data available for Kuwait and inform future public health policy. Hospital policies and staff training are needed to promote the early initiation of breastfeeding and to discourage the unnecessary use of infant formula in hospital, in order to support the establishment of exclusive breastfeeding among mothers in Kuwait.

Introduction: Spirituality is a concept central to healthcare practice, and in particular to occupational therapy. As a profession, influenced from early Judeo-Christian religious beginnings, occupational therapy has retained yet translated this as a commitment to holistic, person-centred practice. Occupational therapy holds the uniqueness of the individual, and meaningful and purposeful expressions of health and well-being through occupation, as central to professional practice. Set in the context of 21st century healthcare, this thesis explored how occupational therapists (n=4) working in the English National Health Service (NHS) embedded spirituality into daily practice. Methods: Two studies were undertaken, first a structured literature review and concept analysis, applying the method outlined by Walker & Avant (2011), to conceptualise spirituality as described in occupational therapy practice. Second, a qualitative study was undertaken, underpinned by an ethnographic approach, using participant-as-observer observation and follow up interviews to explore how occupational therapists embedded spirituality into everyday practice. Framework approach was used to guide analysis and interpret the large volume of unstructured textual data. Findings: Despite the difficulties defining spirituality occupational therapists appeared able to apply the underpinning core values and philosophy of the profession and embed spirituality in their practice. Practitioners found it more meaningful to describe spirituality in terms of how they applied the concept in, and through, practice by comprehending the values, needs and concerns of the individual as opposed to a consistent definition. Occupational therapists engaged with spirituality by concerning themselves with supporting patients experiencing vulnerability due to disruption in their health and well-being. This support was achieved by the occupational therapist uncovering the individual needs of the patient and through delivering person-centred care by explicitly addressing spirituality. The scope to embed spirituality was on occasion limited by organisational and contextual factors that restricted the potential to practice fully. Achieving organisational targets by adopting time constrained interventions was perceived as having a particularly limiting impact on embedding spirituality in practice. Conclusion: The Embedding Spirituality into Occupational Therapy (ESpiOT) model which emerged from the findings of this study is offered as a tool to guide practice, education and research into how spirituality is, and could be, embedded into occupational therapy practice.

This is the thesis (critical appraisal) component of a PhD by Published Works. The overall submission was a portfolio of ten published papers supported by a critical appraisal focusing on two key areas: an exploration of the roles that Health Information Professionals (HIPs) can play within evidence based practice (EBP) and an exploration of the effectiveness and impact of the traditional supportive role played by HIPs within EBP. The published papers are listed and referenced within this document but not contained within it. The majority are available elsewhere within the University of Salford Institutional Repository. Drawing on a model developed from the library literature, the thesis highlights a wide range of supportive and active roles that HIPs can potentially play within EBP. This model is informed and illuminated by the studies within the portfolio that demonstrate how the author has fulfilled a wide range of these roles in practice, and identified a new role within systematic reviews in health and social care. This demonstrates that HIPs can transfer their skills outside their traditional library and information practice domain, thus extending their role and offering a range of professional opportunities. Using a varied range of research methodologies, the thesis also explores the effectiveness and impact of the contribution made by HIPs when using traditional skills to support EBP. Two models are used to illustrate the outcomes to which HIPs contribute. These include improving search skills and providing evidence which can, over the longer term, contribute to policy making and patient care. At present the weight of the evidence presented to support these links is weak. Methodological issues and future research that needs to be addressed to improve the strength of the evidence base are therefore highlighted and discussed.

The aim of this study was to model the process of development for an Online Learning Resource (OLR) by Health Care Professionals (HCPs) to meet lymphoedema-related educational needs, within an asset-based management context. Previous research has shown that HCPs have unmet educational needs in relation to lymphoedema but details on their specific nature or context were lacking. Against this background, the study was conducted in two distinct but complementary phases. In Phase 1, a national survey was conducted of HCPs predominantly in community, oncology and palliative care services, followed by focus group discussions with a sample of respondents. In Phase 2, lymphoedema specialists (LSs) used an action research approach to design and implement an OLR to meet the needs identified in Phase 1. Study findings were analysed using descriptive statistics (Phase 1), and framework, thematic and dialectic analysis to explore their potential to inform future service development and education theory. Unmet educational need was found to be specific to health care setting and professional group. These resulted in HCPs feeling poorly-equipped to diagnose and manage lymphoedema. Of concern, when identified, lymphoedema was sometimes buried for fear of overwhelming stretched services. An OLR was identified as a means of addressing the unmet educational needs. This was successfully developed and implemented with minimal additional resources. The process model created has the potential to inform contemporary leadership theory in asset-based management contexts. This doctoral research makes a timely contribution to leadership theory since the resource constraints underpinning much of the contribution has salience to current public services. The process model created has the potential to inform contemporary leadership theory in asset-based management contexts. Further study of a leadership style which incorporates cognisance of Cognitive Load Theory and Self-Determination Theory is suggested. In addition, the detailed reporting of process and how this facilitated learning for participants contributes to workplace education theory.