This thesis examines the ways in which a deeply entrenched nursing hierarchy is being reconfigured and challenged, and the status of nurses reshaped, in relation to wider political and social processes in the post-apartheid context. Specifically, it offers an ethnographic analysis of nurses working at Bethesda Hospital, a rural government hospital in northern KwaZulu-Natal. It argues that at this moment of liminal uncertainty characterising the current political and social transformation, nurses’ experiences are made meaningful both through a nostalgic reconstruction of the hospital’s missionary past, as well as through idioms that generate opportunities for – and a sense of control over – the future. These are all manifestations of a contemporary post-apartheid moment, yet they are also extensions of longer historical processes. This thesis, therefore, poses important questions about the nature of ‘transition’ in South Africa, and to what extent this has been marked both by rupture and continuity, in the localised context of a rural government hospital and its surrounding area. The thesis begins with an historical account of Bethesda hospital from its inception in 1937 as a Methodist mission hospital, and its eventual transfer to state control, describing a complex and changing micro-struggle for power in the context of a wider political economy of health care. It goes on to consider the influence of the hospital’s mission past on current practices, exploring the ways in which nostalgic memories feed into contemporary workplace debate. Such debate is framed by a context of severe and widespread ill-health exacerbated by the HIV/Aids epidemic, and the problems of staff shortage, fragmentation and poor pay and working conditions that provide ongoing and critical challenges to the institution and its employees. It considers how the moral concern provoked by this perceived crisis, and the preoccupation with hierarchy that has long been a feature of the South African nursing profession, are played out in relation to the emerging post-apartheid ideologies of ‘accountability’ and ‘rights’. Finally, it explores the ways in which nurses generate a mutual sense of purpose and control, while at the same time engaging in embattled struggles for status and self-recognition, through the practices of Born-again Christianity and international migration, showing how these offer new and powerful forms of status acquisition in the post-apartheid context. Based primarily on ethnographic fieldwork conducted at Bethesda hospital between December 2006 and October 2007, this thesis engages with theoretical discussions about social change and relationships of hierarchy within – and beyond – the workplace. Finally, it contributes to debates about the shifting fields of nursing and health care delivery in the wider South African context of immense political and social transformation.

Infancy is a time of rapid physiological (e.g. anthropometric, immunological and neurological) development. Hence, during this period of life nutritional requirements are at their highest in relation to body mass. There is a paucity of data with respect to the nutritional quality of complementary foods manufactured in the UK for infants and young children. The primary objective of this study was to examine the nutritional value of ‘ready to feed‘ complementary infant foods on the UK market in order to ascertain their suitability, relative to dietary guidelines, for the target group. Quantitative analysis was conducted on eight different products representing four popular commercial brands (meat and vegetable based) currently on sale in the UK for infants aged between 6-12 months. The chemical analyses conducted included Kjeldhal for protein, acid hydrolysis and extraction for fat, phenol sulphuric acid for carbohydrate and AOAC 985.29 for fibre. The results of these studies were referenced to the Recommended Nutrient Intake (RNI) values for 6 to 9 months old children, and a listing of the entire daily intake of nutrients was composed taking into consideration the nutrient and energy intake from milk consumption in order to (1) accurately estimate the daily intake of these nutrients derived from commercial infant food consumption, and (2) ascertain their nutritional suitability relative to dietary guidelines for the 6-9 month age group. The only significant difference found between different product varieties (meat and vegetable-based) was with respect to the protein content (p = 0.04) per 100 g of food. The experimentally determined concentrations of macronutrients (g/100 kcal) were compared to the declared values provided by the manufacturers on the product labels and, despite some variations, the values obtained comply with regulatory requirements (Commission Directive 2006/125/EC). The total daily intake of fat (27.0 g/day), based on the menu composed from commercial complementary food, is suggested to exceed the Dietary Reference Values (DRVs) for fat (31%), if the intake of snacks and desserts are incorporated. The aforementioned results imply that the formulations of the recipes, based on a standard commercial menu, are of significant importance in relation to the nutritional quality of the diet of infants. In terms of elemental analysis, the concentrations of up to twenty (essential and non-essential) elements in a selected range of sixteen different products representing meat, poultry, fish and vegetable base varieties were established by ICP-OES and ICP-MS. Six major essential elements, namely: calcium, iron, magnesium, potassium, sodium and zinc were measured by ICP-OES. The concentrations of six essential trace elements (selenium, molybdenum, cobalt, copper, chromium, manganese) and eight non-essential, potentially toxic, elements (arsenic, barium, nickel, cadmium, antimony, lead, mercury, aluminium) in chicken and fish-based varieties were determined by ICP-MS due to the higher sensitivity required. Based on the results of elemental analysis, there was also some evidence of a lack of attention to micro-nutrient interactions in food. With reference to the guidelines, the RNI values for 6 to 9 month olds, all samples provided less than 20% of RNI values except for potassium (20%). In terms of the risk of exposure to toxicity, the concentration of non-essential elements in ready to feed products analysed were not considered to be of concern. With regard to the analyses of vitamins, a novel assay for the simultaneous quantitative determination of riboflavin (B2) and pyridoxine (B6) has been developed. The method involves a mild hydrolysis step, extraction of the supernatant by centrifugation followed by quantitative analysis using UHPLC. Separation of the two water soluble vitamins achieved is excellent and rapid - within one minute whilst the resultant sample is also LC-MS compatible. With respect to vitamin B analyses, despite wide individual differences between brands (p = 6.5e-12), no significant differences were observed in the levels of vitamin B6 between the meat and vegetable-based varieties (p = 0.7) per 100 g of commercial infant food. Vitamin B2 was not detected in any of the samples, where the detection limit was below 0.07μg/mL. In terms of the RNI of vitamin B6 for 6 - 9 month old infants, the complementary infant meal products analysed herein provided less than 15% of the RNI values with mean (SD) values of 12.87 (±4.46) % and 13.88 (±4.97) % for the meat- and vegetable-based recipes, respectively. The estimated total daily intake of vitamins B2 and B6 from the consumption of commercial complementary food was found to be satisfactory and in accordance with the DRVs. The intake of both vitamin B2 and B6 was estimated to be mainly derived from the consumption of formula milk which could be a cause of concern if the quality of an infant‘s milk diet is compromised by an inadequate or lack of supplemented milk intake. All the foregoing results suggest that commercial complementary infant foods on the UK market may not contain minimum levels of micronutrients required for labelling declaration of micronutrient content (Commission Directive 2006/125/EC). An attempt, therefore, was made to optimise the formulated version of the meat based infant food as a baseline and measure the post-process retention of its nutrient content after being subjected to different processing condition in terms of a combination of temperature and time. This was achieved by quantitative analysis of the post-process values of the nutrients in the optimised formula using the aforementioned analytical techniques. The results of this study indicates that careful formulation of the recipes, in the context of new product development, is important; the selection of high quality ingredients and the ratios in which they are used have a direct effect on the nutrient content of the final product. It also indicates that a carefully controlled temperature-time combination, pH, pressure and macroscopic conditions of processing (e.g. controlled leaching) are very important in reducing heat loss and improving the nutritional quality of the food product. This provides opportunities and scope for product optimisation, of ready to eat to eat infant foods, in order to improve their nutritional value.

Chronic illnesses are the leading cause of death worldwide and are also expected to be the leading cause of disability by 2020 (World Health Organization [WHO], 2003). They are changing the experience of healthcare for both patients and healthcare professionals. In particular, they are changing the roles of patients and doctors, with patients expected to be more involved in their disease management and doctors shifting their focus away from curing pathology to regulating and palliating symptoms (May, 2005). Chapter one presents a systematic review of the role of patients' relationship styles on healthcare outcomes in diabetes. Outcomes of the review highlight the impact of attachment styles that are characterised by having a 'negative model of other' on health outcomes. Despite methodological limitations, the review finds evidence to support the use of attachment theory for understanding healthcare outcomes in the diabetes population and describes the clinical utility of using attachment theory in the development of interventions with this patient group. Chapter two examines the experiences of healthcare professionals in chronic illness in an empirical study investigating the lived experiences of the long term doctor-patient relationship in male Consultant Nephrologists. The experiences of seven Consultant Nephrologists were explored using a phenomenological approach. Findings revealed three superordinate themes: 'Defining my professional identity', 'Relating to the patient' and 'Coping with the job'. Clinical implications of the findings and recommendations for future research are discussed. Chapter three continues the theme of healthcare relationships in a reflective paper based on a journal kept by the author throughout the research process. This paper considers the challenges of conducting psychological research in medical settings, in particular, the researcher’s own initial reservations about these challenges and how the researcher feels now the study is complete. Such reflections may be beneficial for psychologists conducting future research in this area.

Understanding the complexities associated with physical activity behaviour is problematic as it is a complex phenomenon that the majority of the population do not engage with. Sedentary lifestyles have been associated with a range of diseases, more prevalent in areas of social deprivation than in affluent areas. The objective of this research was to gain a comprehensive understanding of the experiences of a group of patients and their referring health professionals, in respect to what the experience meant to them and its impact on their lives. A qualitative longitudinal approach was used to maximise the ecological validity of the study. The practice based exercise referral scheme took place in a South West Devon city. The data collection phase comprised of two parts. Twelve interviews were carried out with referred patients on three occasions (0, 8 and 12 months). The second phase consisted of six interviews with the referring health professionals on two separate occasions (0 and 8 months). Grounded theory methodology guided the analysis resulting in two conceptual models. The first model emerged from the health professional’s data. It depicted the context in which the patients were referred into the scheme and represented the phenomena ‘patient take-up of a practice based exercise referral scheme’. The second model emerged from the patient’s data, depicted the context in which the patients experienced the scheme and represented the phenomena ‘the impact of long term involvement with an exercise referral scheme on patient’s perceived health status. These findings were interpreted further to gain insights into the core categories of ‘easier referral’ and ‘feeling better’, which emerged from the first and second models respectively. The analysis highlighted the multidimensional nature of these two categories. ‘Easier referral’ embraced a wide range of notions. For example, structural systems, interactional tactics and training needs. Barriers to referral included not prioritising referrals and gender stereotypes. Enablers included tactics to engage the patient with the scheme. ‘Feeling better’ embraced a wide range of beliefs held by the patients. For example, the impact of the scheme on perceived health status, the impact of sedentary behaviour on disease aetiology and the support systems necessary for adherence. Key motivators for adherence were, feeling good, health status and medical implications. Through unpacking the two concepts of ‘feeling better’ and ‘easier referral’ the findings provide new knowledge on the potential that exercise referral schemes have to improve long term quality of life for patients. The findings also suggest methods that health professionals can improve patient take-up of schemes. This insight can inform researchers and future evaluation design of exercise referral schemes to be more representative of the genuine long term impact on the health of patients. Future schemes would benefit by developing: engagement tactics; training to reduce risk to health professionals; fostering gender neutral patient perceptions; and identification and use of support systems by exercise professionals. This context specific evidence adds to the current research and as such can inform future practice and research. This study has shown that a practice based exercise referral scheme can enable patients to develop long term physical activity behaviour, apply learnt behaviour to their lifestyles, help to manage medical conditions and improve perceptions of health status.

The National Institute for Clinical Excellence (NICE) recommends that the treatment of eating disorders should generally be managed on an outpatient basis using psychologically informed approaches (Clinical Guideline 9, NICE, 2004). As such, carers and psychological therapists are crucial in providing support to individuals with eating disorders. Although there is a wealth of research literature focusing on the understanding and treatment of eating disorders, further consideration of carers and therapists in this area is warranted. This thesis therefore gives prominence to these two groups. Chapter 1 reviews the literature on education and support interventions for carers of those with eating disorders. Findings suggest that face-to-face and self-help interventions show effectiveness in reducing negative carer symptoms and meeting carers’ needs. Methodological limitations, research recommendations and clinical implications are outlined. Chapter 2 presents an empirical study which explores the impact of eating disorders work on eight psychological therapists, including the effects on their eating and body image. A grounded theory approach is adopted. Findings illustrate that therapists are affected by the complexity of their day-to-day work in many ways and that they have a number of means of coping. Recommendations are made for clinical practice and future research. Chapter 3 provides a reflective account of the research journey. It gives an overview of the research process and provides an opportunity for the researcher to be considered in this.

Traditionally the biomedical approach has characterised dementia care. This approach predominantly attributes the patient's presentation and deterioration to the dementia. A more holistic approach to dementia care involves considering a range of factors, in addition to the dementia, that may account for the patient's presentation and deterioration; these include psychogenic, biogenic, social and environmental factors. The current thesis sought to explore the impact of some of these potential factors. Caregivers play a vital role in looking after people with dementia. Caregiver presentation may be impacted directly by caregivers' own psychogenic, biogenic, social and environmental factors, as well indirectly by care-recipient psychogenic, biogenic, social and environmental factors. The current thesis sought to explore the impact some of these potential factors on caregiver presentation, in an attempt to further understand some of the reasons underlying positive and negative caregiving experiences. Chapter 1 details a review of the literature investigating the associations between Attachment Style/dimension and clinical presentation in people with dementia and caregivers. Chapter one thus explores a possible psychogenic factor influencing the presentation of people with dementia and caregivers. Chapter 2 is a piece of empirical research investigating how a co-morbid physical health problem suffered by a Person with Dementia (PwD), specifically infection, impacts on a PwD as well as on their caregiver; the impact of hospitalisation of the PwD is also explored, both on the PwD and on their caregiver. Chapter two thus explores possible biogenic, social and environmental factors influencing the presentation of people with dementia and caregivers. Chapter 3 details some of my reflections on and learning from the process of conducting this empirical research.

This thesis explores the issues around stress in the UK Health Service, with a particular focus on stress in the Hospice Service and the benefits of a group coaching intervention for this staff group. Section A provides an introduction to the thesis, explaining the rationale behind the choice of research and how the different sections link together. Section B reports on the research aspects of this thesis which exists of three phases. Phase 1 is a cross-sectional study to assess the levels of stress and the main work-stressors as experienced by members of staff working within two hospices in the UK. Phase 2 is a qualitative study using two focus groups, one at each hospice, to obtain a deeper understanding of the findings of phase 1. Phase 3 is an evaluation of a brief group coaching intervention for stress management, which has been informed by the findings of phase 1 and 2. The theoretical framework of the coaching intervention was Cognitive Behavioural Coaching (CBC). Section C of the thesis presents a case study of a one-to-one stress-coaching intervention. This study also uses CBC as its theoretical framework and uses the same coaching format as was used in the group coaching session described in section B. Using the same model for both the group and one-to-one coaching intervention provides an opportunity to explore the versatility and usefulness of CBC within the context of stress coaching. The critical literature review presented in section D of the thesis examines the effectiveness of traditional stress management programmes used within the nursing profession, which provides a base-line for the development of an effective coaching intervention. The findings of this thesis add to the current understanding of stress in the UK hospice service and provide the foundations of a new approach to staff support and stress management within the Health Service using a CBC coaching model.

The aim of this study was to develop a method for measuring an individual's fat content, which was both simple and inexpensive and could therefore be used by relatively inexperienced researchers in large scale field studies. At present the most popular field methods for assessing 'overweight' are weight for height tables based on Insurance Company data, and weightheight indices. The methods chapter points out the major limitations of these methods and describes how they cannot differentiate between weight due to bone, muscle, water or fat. Another popular field method is to measure skinfolds at a few predefined si tes and convert these to a fat content using regression equations. Al though this method allows 'fatness' as opposed to 'overweight' to be assessed in the individual, it has the disadvantage that the observer requires some training, which is not· always feasible, and carefully calibrated skinfold calipers are essential. It is for these reasons that a new field method, requiring minimal training and equipment was sought. This study was carried out on a group of 6,495 males and 2,304 females aged 16-64y, selected, as described in Chapter 2, from both the British Armed Forces and the civilian population. The measurements taken from each individual were height, weight, 4 circumferences, 4 boney diameters and 4 skinfolds. Using the equations of Durnin and Womersley (1974) and Siri (1956) the skinfolds were converted into a value for percent body fat, and fat free mass (FFM) was calculated by subtracting fat mass from body weight. The height and weight results were compared with the results of the Office of Population Censuses and Surveys (OPCS), 1981, UK survey. Since the OPCS survey was believed to be representative of the UK population, the comparison allowed an assessment of possible sampling errors. Variations in' anthropometric results related to geographical origins and social class (SC) were also examined, within Chapter 3, together with age related changes. Within the Forces, civilians and OPCS samples respectively, mean height had values of 175.9cm, 175.6cm and 173.8cm. Within the female samples, these 3 values were 163.6cm, 162.4cm and 160.7cm. The differences between the 3 populations were due mainly to the facts that the Forces selection procedure includes a minimum height cutpoint for many occupations and that the civilian selection was not very random. When predicting percent fat or FFM however, these differences appeared to be relatively unimportant. Although height appeared to vary little with age, it did vary in relation to geographical region. In general, -the northern regions had slightly smaller means for most of the anthropometric measurements, when compared to the southern regions. In addition, there was a slight tendency fof height to decrease with se. Mean weight increased with age from 65.5kg in the Forces male 16y olds to 80.0kg in the 5O-56y olds. The Forces and civilian females kept their .weight around 61 and 57kg respectively, between 17 and 29y, after which it rose steadily. Most of these weight increases were due to increases in fat content, since between the 16-17y and over 50y olds, mean percent fat rosefrom 13.4% to 27.2% and from 28% to 35.7% in the Forces males and females respectively. FFM also varied slightly with age, especially in the male sample. In the male Forces it averaged 56.5kg, 61.8kg and 59.6kg in the 16y, 25-29y and 50-56y olds. The initial rise was mainly reflecting growth in the younger subjects. The subsequent changes are discussed in detail in Sections 3.2.10 and 3.2.11. When matched for height and age the Forces males had FFM values on average 2.5kg larger than the civilians and this reflected a larger mean 'build'. This had to be taken into account in order to produce prediction equations applicable to both populations. There was little difference in fat content between the 2 groups. The Forces females were of a similar 'build' to the civilians, but on average 1-2% of body weight fatter. regression equations. This made no difference to the Section 3.4. describes the calculation of regression equations which predicted fat content and FFM. Although initially both FFM and percent fat were used as dependent variables, the prediction of FFM was the more accurate and therefore it was used in preferance. The males were ini tally divided into height, weight then age groups but since the regressions predicting FFM in age groups were the most accurate, age was chosen as the final grouping variable in both sexes. The number of age groups depended on the similarities between different ages, and was calculated using a F-test. Using the BMDP package of computer programmes, the variables height, weight, calf circumference and ulnar diameter were chosen from those measured as the 'best' to predict FFM in the male sample. In the females, the 'best' variables were height, weight and upperarm circumference. The regression equations are in Tables 90 and 91. The final 7 male and 2 female age related regression equations were ini tially calculated from the Forces data, and cross validated on the ci vUian sample. The range of standard errors of the estimates (SEE) in· both samples was 1.54-2.39kg in the males and 1.44-1.80kg in the females. Approximately 95% of the prediction errors would lie within! 2xSEE• Overall, FFM and hence percent fat could be predicted with greater accuracy using these regression equations than using weight-height indices or tables. The method is also simple enough to be used by untrained observers, in field studies.

Colorectal cancer is a significant cause of morbidity and mortality in the West of Scotland. Socio-economic circumstances are known to be related with variations in health behaviour, risk factor exposure and outcome for a variety of diseases. However, the relationship between socio-economic circumstances and the risk of developing and surviving from colorectal cancer have been inconsistently reported using a variety of methodological approaches over recent decades in this region. Therefore, the principal aim of this body of work was to explore the relationship between socio-economic circumstances and the mortality, incidence and survival from colorectal cancer in the West of Scotland using robust methodology. Firstly, a population-based study was undertaken to explore recent temporal trends in colorectal cancer-specific mortality and the relationship with socio-economic circumstances. Incidence data from the Scottish Cancer Registry (SMR06) were linked to General Registry Office for Scotland (GROS) death records to produce age-standardised colorectal cancer-specific mortality rates. From 1985 to 2007, both colon and rectal cancer-specific mortality fell among women but remained unchanged in men. From 1996 to 2007, increasing levels of socio-economic deprivation were associated with higher rates of rectal cancer-specific mortality in both sexes and colon cancer-specific mortality in males only. This socio-economic inequality accounted for an estimated 859 excess deaths from colorectal cancer over 12 years in the West of Scotland. Further study of the underlying influences of the association between socio-economic deprivation and colorectal cancer-specific mortality was subsequently performed. Secondly, a population-based study to explore temporal trends in colorectal cancer incidence and the relationship with socio-economic circumstances was performed. Incidence data from the SMR06 were used to produce age-standardised incidence rates of colorectal cancer. From 1981 to 2007, colon and rectal cancer incidence rates increased significantly among men while remaining stable among women. From 1996 to 2007, the incidence rate of colon cancer in either sex and female rectal cancer were not associated with socio-economic circumstances. However, from 2002 a relationship between deprivation and a higher incidence of male rectal cancer became evident due to a significant reduction in incidence among the most affluent men. This emerging socio-economic inequality accounted for an estimated excess of 286 cases of male rectal cancer over the 6 year period to 2007. Subsequently, a detailed examination of temporal trends in relative survival following the diagnosis of colorectal cancer was performed. The relationship between survival from colorectal cancer and socio-economic circumstances was also examined using a population-based approach. SMR06 and GROS death record data were linked and relative survival analyses were performed. From 1991 to 2005, 5-year relative survival from colon and rectal cancer significantly improved in both sexes, especially in the first year after diagnosis. From 1996 to 2005, deprivation was associated with poorer survival from male colon cancer and rectal cancer in both sexes. This “deprivation gap” at 5 years arose due to early survival differentials between socio-economic groups in the first year after diagnosis. Furthermore, patients from the most deprived areas were more likely to be older at diagnosis, have rectal tumours, present with more advanced stage disease and were more likely to undergo non-curative treatment compared to the most affluent group. The association between deprivation and poorer survival was also found to become progressively stronger as stage of disease became more advanced. Even after adjustment for other factors associated with survival, deprivation remained independently associated with poorer survival, especially in the first year after diagnosis. Finally, to examine the association between socio-economic circumstances and short and longer-term survival after surgery for colorectal cancer, a study using clinical audit data linked to SMR06, Scottish Inpatient and Day-case Morbidity (SMR01) data and GROS death records was performed. From 2001 to 2004, this study confirmed that deprivation was independently associated with poorer post-operative (<30 days) and 5-year relative survival following surgery for colorectal cancer. Higher post-operative mortality among patients from more deprived areas was the main determinant of the longer-term deprivation gap in survival. This suggests that the main determinant of the observed longer-term socio-economic survival gradient occurred within the early post-operative period in patients undergoing surgery for colorectal cancer. Poorer short-term survival after surgery is likely to be influenced by higher levels of medical co-morbidity and reduced physiological reserve among more deprived groups. Therefore, by using a variety of data sources and robust methodological approaches, this thesis explores the relationship between socio-economic circumstances and colorectal cancer mortality, incidence and survival over recent decades in the West of Scotland. It demonstrates that deprivation was associated with poor short and longer-term survival, high cancer-specific mortality rates and became associated with higher rates of male rectal cancer incidence in the West of Scotland. These findings suggest that early survival differentials play a significant role in the observed deprivation gap in longer-term outcomes. Successful strategies to tackle this inequality are likely to involve multimodal interventions aimed at overall health improvements that are equitable to all. Strategies to improve early detection of colorectal cancer including national bowel screening initiatives and public health campaigns need to be further evaluated and, should they prove effective, tailored to ensure that high risk groups are engaged to participate. Additional interventions aimed at reducing post-operative mortality and morbidity in high risk individuals may also help reduce the observed socio-economic inequality in longer-term outcome. However, further detailed research using high-resolution prospectively collected clinical audit data is required so that modifiable determinants of socio-economic survival inequality can be identified to target future interventions.

An initial review of the literature concerning anticipatory grief was executed to foreground a qualitative study focusing on the experience and conceptualisation of loss by adult daughter caregivers in dementia. A chronological overview was presented and key studies and major developments identified. Inconsistencies in empirical findings were summarised; and preceded a consideration of methodological issues including: problematic research design and definitional confusion regarding conceptual underpinnings. Key recommendations for further research were made. The main study adopted a grounded theory methodology and sought to explore the nature and process of losses experienced by daughters providing care for a mother with dementia. Open, in-depth interviews (N=10) functioned as the primary data source for analysis. Further data included: participant notes and letters; demographic details; researcher's notebooks and reflective and analytical memos. Concurrent data collection and analysis proceeded, in three phases, and the resulting, emergent, theoretical model was presented using Strauss and Corbin's (1990) framework. A full explication of the model followed and its relationship to relevant literature elucidated. Implications for clinical practice and further research were addressed. In the course of analysis it was noted that caregivers made reference to existential themes in their accounts of caregiving. This precipitated a further study in which Reker and Wong's (1988) dimensional model was used to guide the content analysis of the existing transcribed interview data. Findings indicated that participants expressed existential themes at both an implicit and explicit level. Considerable breadth, depth and diversity was observed in relation to caregiving experienced. Caregiving appears to pose both existential challenges and opportunities for growth. Implications for clinical practice and further research were identified.