Aims The aims of the study were to explore how emergency department (ED) nursing staff conceptualise the terms that encompass violence and aggression in the clinical area; to explore the formal reporting practices of nursing staff following such experiences and to explore situational factors at play, relating to the development of violent and aggressive incidents in the ED setting. Background Violence and aggression experienced by ED nursing staff is a well recognised, global phenomenon. Published research exploring ED violence and aggression however is limited, both numerically, and in terms of quality and sophistication. The literature review conducted for this study identified very few studies that considered defining violence and aggression in the ED setting. The literature suggests that ED nursing staff frequently fail to formally report experiences of violence and aggression and factors influencing reporting practices tend to be speculated upon rather than researched. A wide variety of situational factors are identified in the literature as contributing towards violence and aggression in the ED setting, although, only a limited number of original research papers have contributed new knowledge in this field. This study was subsequently conducted for the award of a Doctorate of Education and focuses upon educational factors, within the context of the research aims and emerging themes that can be perceived as relevant to the phenomenon of ED violence. Methodology and research design The study was undertaken from August 2007 to May 2009 at a site specific, National Health Service (NHS), acute hospital ED in the south of England. Adopting an interpretive paradigm, data was collected and analysed within a grounded theory framework. Data triangulation was employed, with the researcher conducting a retrospective documentary inspection of ED violent incidents forms completed by nursing staff (n=38), semi-structured interviews with ED nursing staff (n=9) and periods of non- participant, unstructured observation (n=17). Findings The study identified multiple examples of conflict in the ED, including nursing staff personally experiencing, witnessing, or being aware of physical assaults on staff. This included both physical assaults involving weapons, along with high levels of verbal abuse. The study also identified the phenomenon of service user-on-service user conflict, an issue previously not considered in ED literature. The findings highlighted that individual nursing participants considered a variety of complex factors when subjectively and inconsistently defining, assessing, managing, responding to and reporting workplace conflict. A wide variety of inter-related factors contributed to how participants defined violence and aggression, although the dominant theme that emerged related to inconsistent practice. A failure to clarify the concepts encompassing violence and aggression contributed towards a culture of under-reporting of incidents; although incident frequency and a perception by participants that formal reporting was a futile exercise that did not lead to change, were also highlighted. Some participants expressed a disempowered attitude towards working conditions, which limited a proactive approach to maximising personal safety in the department studied. A cocktail of potential situational factors was in addition identified, as contributing to conflict in the ED studied, in particular: poor corporate security, poor departmental design and infrastructure, negative service user attitude and behaviour. Stress, service user demographics, confrontational staff communication strategies and a limited proactive approach to managing violence and aggression in a professional manner at both personal and corporate levels were also cited. Although the study had 3 pre-determined research aims; from an educational perspective, 4 key themes emerged. These related to a limited evidence-based approach to managing ED violence, due to a paucity of research; particularly research conducted by clinical nursing staff. Inconsistent practice in assessment, management and reporting of ED violence, challenging working conditions compromising personal safety and stifling potential research opportunities, and a disempowered attitude displayed by some participants in relation to managing their occupational circumstances proactively. The data collected, during this study, in addition, highlighted multiple examples of participants being aware of, or potentially being involved in, practices that contravene the Nursing and Midwifery Council (2008) Code of conduct, performance and ethics for nurses and midwives. Conclusion The data collected during this study can be interpreted as suggesting that ED violence and aggression is poorly documented; the subject matter remains unclarified in clinical practice; specific incidents of violence and aggression are inconsistently assessed and managed and that there is a cocktail of factors which contributes towards the development of conflict in the ED. Two central, core categories were identified during this work; and labelled as professional nursing identity, and professional maturity. The findings of this site specific study challenge the foundations of the nursing profession in terms of claims of professional status, as the data collected is incongruent with the characterisation of the attributes and traits of professional status. Nursing identity relates to participants expressing widely differing views relating to the actual role of the ED nurse. This subsequently manifests as variations in the documentation, assessment, management and attitude of staff towards service users involved in conflict with staff. Professional maturity relates to the limited research literature available examining this field, particularly research conducted by clinical nursing staff. This can be interpreted as reflecting a wider professional failing to embed a genuine research culture into the nursing profession. Professional maturity also relates to participants complying with the NMC code (2008). One can propose that as the nursing profession develops and matures, individual members may project enhanced professional values which could lead to improved workplace circumstances. Currently, ambiguity and inconsistent practice characterise the nursing response to ED violence. This may be potentially rectified through a variety of higher educational (HE) initiatives designed to proactively and positively influence the two central core categories identified above. Educational recommendations relate to encouraging a policy shift in the HE sector to promote the development of genuine professional autonomy. This could be achieved through placing emphasis on facilitating the development of under-graduate nursing students as potential future researchers; by formally requiring under-graduate degree nursing students to engage in original data collection research activities. HE institutions should also strive to empower under-graduate nursing students to challenge current occupational workplace conditions, through a transformational leadership approach emphasising the development of confident, assertive, and politically astute nurses of the future. Clarification relating to defining violence and aggression in the healthcare context, a review of current formal reporting procedures, a review of corporate security at the site examined, a wider debate relating to the role of the ED nurse, and increased research and education focusing upon ED violence and aggression are all suggested as further recommendations.

This thesis consists of three papers, a literature review, an empirical paper and a reflective paper. The literature review covers two distinct but interlinked areas of research: the impact of dementia on the quality of relationships, and the impact of relationship quality on the experience of living with dementia. The literature review clarifies the interactions between these factors by using a model to demonstrate the influence of relationship factors on the experience of living with dementia. Methodological issues and suggestions for future research are discussed, and the findings are summarized with particular reference to clinical implications. The empirical paper reports on a study of the awareness of carer distress in people with dementia. Ratings of carer psychological health were elicited from people with dementia and from the carers themselves as a pair. Comparison of the ratings showed that people with dementia are aware of their carers' psychological health. A control group of people with arthritis also participated in the study. The level of awareness shown by the participants with dementia was comparable to the level of awareness of carer psychological health shown by the control group. The level of awareness of carer psychological health in the participants with dementia was not related to their level of awareness of their own memory difficulties. The thesis concludes with a reflective paper which focuses on observations made whilst conducting research interviews and recruiting participants through support groups. Reflections and learning drawn from these observations are discussed.

This research examined therapeutic approaches to trauma and post traumatic growth and recovery as a result of brief psychological intervention. Chapter one is a critical review of current therapeutic approaches used in the treatment of trauma and post traumatic stress disorder, PTSD. The PTSD treatment literature indicates that the therapy most rigorously assessed and currently recommended by the National Institute for Clinical Excellence (NICE) is trauma-focused Cognitive Behavioural Therapy and Eye Movement Desensitization and Reprocessing. Despite this, the literature review indicated that other forms of therapy have been effective in reducing the symptoms of PTSD. The research indicated that clinicians are successfully using psychodynamic, integrative and person centred approaches in both an individual and group therapy format. Regardless of therapeutic approach used, issues of client motivation, timing of therapy and therapeutic alliance were important determinants in outcome. Chapter two is an empirical study, which focuses on the effect of brief psychological intervention on recovery from trauma. A mixed methodological design was used and five participants took part in the research. The results indicated that those participants whose trauma symptoms reduced had experienced recovery from their trauma. Participants cited underlying beliefs towards adversity, personal and contextual factors as important in facilitating recovery. Recommendations for further research and clinical implications were discussed. Chapter three provides the authors reflections upon the research process and methodological and ethical issues that arise when carrying out qualitative research with a trauma population.

This thesis investigated current praxis among professional interpreters working in psychiatric outpatient clinics. The research question asked whether there are models of interpreting practice, and whether or not they are being used. A qualitative approach was taken based on hermeneutic phenomenology, and thematic analysis was used to analyse multiple types of data. Two clinicians and eight certified and registered interpreters were interviewed with part of the interpreters’ interview consisting of responses to dilemma vignettes. A Delphi process validated responses to these vignettes. Four clinical encounters at routine appointments in psychiatric outpatient clinics were filmed and analysed using thematic analysis; post hoc satisfaction questionnaires were used after the filmed interviews. The complexity of interpreters’ work was revealed in the breakdown of the components forming the impartial interpreting model. Taking the model as the cognitive framework for observation of practice provided depth of insight into the whole communication event. A tension between doctors’ and interpreters’ understandings of each other’s roles and professional needs revealed that each believed themselves to be helping the other, when in fact they were working against each other. The impartial model was seen to be in use, but only in part, and interpreting practitioners were revealed to consider close interpreting and the full impartial model as not appropriate for mental health clinics, but only for courts of law. There were noticeable gaps among the interpreters in their education and training for this work. The clinicians declared a lack of training on joint working with interpreters, and this was evidenced in the course of their interviews. This thesis highlights the complexity of need that faces the profession of public service interpreting especially in terms of standardising both training and praxis.

Background: A substantial increase in the incidence of chronic non-communicable diseases (NCDs) and a decline in communicable diseases and poverty-related diseases are occurring in developing countries (including Nigeria) as a result of an epidemiological transition. Given the burden and poor outcomes of NCDs related to hypertension or high blood pressure (BP) in adulthood, there is an urgent need for the identification of high risk individuals in early life. High BP has already been reported amongst young people worldwide, including Nigeria. High BP in childhood is predictive of high BP in adulthood. There is very little information available on the distribution of blood pressure in children and adolescents, and the factors which determine its distribution in Nigeria. Objectives: To determine the association between: socio-economic characteristics and blood pressure, pubertal maturation status and blood pressure, and anthropometric measures of adiposity and blood pressure in children and adolescents in Nigeria; and also to determine the overall prevalence of hypertension in the population of secondary school aged children and adolescents in Nigeria. Methods: A school-based stratified randomised cross-sectional survey of students aged 11 to 18 years was carried out in the urban area of Lagos, Nigeria. Blood pressure, body weight, height and waist measurements of the participants were obtained. A self-complete validated questionnaire was used to obtain sociodemographic information, health-related information, socio-economic characteristics (including living circumstances and parent/carer education level) and pubertal maturation status of the participants. Data analysis was carried out using descriptive statistics and multiple regression analysis. Results: 1086 students (538 males and 548 females) participated in the study, giving a total response rate of 90.5%. The overall mean systolic and diastolic blood pressure was 105.23±12.63mmHg and 57.87±8.09mmHg, respectively. The overall prevalence of hypertension was 2.5%. Socio-economic characteristics, pubertal maturation status, body mass index and waist circumference were statistically significantly associated with systolic and diastolic blood pressure (p<0.05). Conclusion: This study suggests that the epidemiological transition exists and is having measurable effects in school children in Nigeria. The findings highlight the presence of hypertension, and also the need for investigation of factors associated with blood pressure in children and adolescents so as to guide health policy, public health preventive interventions and health practice for child and adolescent hypertension. This study has long term implications for an extra burden of chronic non-communicable diseases related to hypertension in Nigeria.

In common with other areas of public services, recent years have seen a shift in the National Health Service (NHS), with increased power and authority transferring from professionals towards the users of services. As a result, user involvement has come to form a central element of government policy on public services, and health in particular, with a series of specific policy commitments to give users a stronger voice and to involve them in the health service having been published by both the Westminster and Scottish parliaments. These seek to increase users’ involvement in making decisions about their own care and treatment, in examining and improving the quality of services and in policy and planning activity. In doing so, this policy aspires to respond to the changing culture of personal and societal expectations of health and the health service; to build democratic participation in the difficult targeting and rationing decisions faced by health agencies and, thus, to help renew public trust and strengthen confidence in the NHS. These are ambitious aims with far-reaching implications as they represent a transformation in the interaction between users, health professionals and health policy makers. This thesis examined how this policy has been understood and implemented in the NHS by exploring the scope, relevance and quality of the user involvement processes available in three health service settings. In order to develop a better understanding of the issues in user involvement it explored the nature of user participation; the character of user representation and the barriers and facilitators to user involvement in maternity, gynaecological oncology and mental health services. The study examined the response to this policy within these three settings; the functioning of existing user involvement mechanisms and their capacity to involve users in determining their individual health care and in shaping health services and policy to their definition of need. From this examination it defined the key features of a model process for user involvement within the professional service culture and organisational ethos of the NHS. The study then drew conclusions on the capacity of these current user involvement processes to deliver on the policy directive to develop both individual treatment and health services in ways that are responsive and accountable to users. Finally, the thesis identified those areas that require further research before proposing the lessons for the further development of this significant and potentially influential policy directive.

POPULATION AGEING IN SCOTLAND - IMPLICATIONS FOR HEALTHCARE EXPENDITURE Population ageing is a major concern for developed countries in terms of public expenditure required to pay for health care (HC). The broad aim of this thesis is to contribute to and expand the debate on the independent effects that population ageing and the time immediately before death (TTD) have on HC expenditure in Scotland. This study analyses, for the first time in Scotland, how HC expenditure projections are influenced through the application of two approaches; the first only accounting for an increasing proportion of the elderly population, and the second also implementing a TTD component. Several issues that are under-researched or have not been addressed in TTD studies previously, are explored and alternative approaches are presented. Utilising two large linked datasets this thesis addresses important methodological issues. Alternative methods to cost inpatient hospital stays are examined as this has pivotal implications for any analysis undertaken to estimate the independent effect of TTD and age on HC expenditure. Explanatory variables that have previously not been considered, such as health risk and health status measures at baseline, are included in these analyses. The issue of sample selection, arising through the inclusion/exclusion of survivors in a TTD study is investigated and the impact of individuals’ socio-economic status on costs is examined. The analysis of alternative costing methods clearly showed that any inference that can be made from econometric modelling of costs, where the marginal effect of explanatory variables is assessed, is substantially influenced by the chosen costing method. The application of a Healthcare Resource Group (HRG) costing method was recommended. This study found that TTD, age and the interactions between these two factors were significant predictors for HC expenditure. The analysis further identified some of the health status and health risk measures to be important predictors of future HC expenditure. An examination of how sample selection impacts on estimated costs at the end of life showed that if survivors were excluded from the analysis, costs might be overestimated. Drawing on a representative sample of the Scottish population, the investigation of the association that the socio-economic status had with HC costs suggested that less is spent on individuals from more deprived areas. This might partly be explained through the decreased probability of accessing hospital services for individuals from more deprived areas. Furthermore, results showed that projected HC expenditure for acute inpatient care for the year 2028 was overestimated by ~7% when an approach that only accounts for the higher proportion of elderly people in a population in the future is being used as compared to an approach that also accounts for the effect that remaining TTD has on costs.

Previous research in the UK and elsewhere has found that housing tenure (i.e. whether the dwelling is owned or rented) predicts mortality and morbidity. This thesis aims to explain whether ontological security (a long term tendency to believe things are reliable and secure as opposed to threatening) is more likely to be associated with owner occupation, and therefore whether it helps to explain the observed association with tenure and health. For the purposes of this study ontological security was operationalised as being formed of three components: protection, autonomy and prestige. A scale was devised to measure ontological security arising from the home through these three components. This scale was included in a postal survey that also included questions on health, housing area, psychological and sociodemographic characteristics. The postal survey was sent to a random sample of adults in the West of Scotland and nearly 300 completed questionnaires were returned. I found that ontological security was associated with owner occupation but not independently of features of housing. Ontological security was not independently related to housing tenure itself. Owner occupiers reported more ontological security from their homes because their homes were in better condition, situated in better areas and of higher value than social renters. Ontological security appeared to be related to health particularly through psychological characteristics. Other reasons for the associations between tenure and health were that owners were on average younger and richer than social renters. This study suggests that social meaning per se may not be health damaging, but that social rented homes might put their occupants at greater health risk because they are in poorer condition, located in more poorly resourced and problem ridden areas and of lower status. These features of social renting may also be observed in other countries (e.g. USA).

Over recent years, designing technologies to promote health-related behavioural change has been an area of growing interest in HCI. Given the prevalence of self-monitoring and social facilitation in emerging designs, the assumption appears to be that increasing an individual’s awareness of his or her behaviour and the behaviour of others will promote behavioural change. This thesis argues that while this is true to some extent, this represents a somewhat naive view of how individuals come to make decisions regarding their health-related behaviours. Three qualitative studies within distinct health domains illustrate the complex nature of health-related behavioural change. Weight Management was an inherently social activity, albeit subject to selective disclosure and incremental participation. Individuals were generally motivated by appearance rather than health, implementing change based on exposure and orientation to alternative strategies. In Families at Risk, caregivers were highly motivated by a desire to safeguard the health of their children but were restricted by a lack of financial and strategic resources. Lack of trust and a transient community contributed to social isolation, thus inhibiting opportunities for collaboration. In Cardiac Rehabilitation, behavioural change efforts were prompted by an acute health crisis and guided by health professionals. However, behavioural change efforts were sometimes restricted by a desire to return to normal, tensions arising when what was considered normal was composed of risk behaviours. Family involvement varied greatly, ranging from disregard to facilitating change, and a desire for independence and ownership of the rehabilitation sometimes restricted the active involvement of peers. Informed by the findings of these studies this thesis highlights the strengths and limitations of current technological approaches to promoting behavioural change, provides implications for design, and supported by the sociomedical literature, identifies alternative avenues of technological innovation. The thesis reflects on technology’s role in health-related behavioural change and considers associated ethical implications. Overall, the main contribution of this thesis is a reframing of the problem of promoting health-related behavioural change as more than a matter of behavioural awareness and personal motivation. While it is understandable that technologists would look to the clinical domain to inform initial investigations in this area, this thesis argues that technologists should be cautious about blindly adopting its prescriptive paradigm. As an alternative to persuasion, this thesis offers negotiation as a potential model for future innovations in this area.

The main questions of this thesis are how a period of in utero malnutrition can impact the health of young children and their later development, and how job promotions can affect health. In the first chapter I analyse to what extent the South-East Asian financial crisis affected the height of Indonesian children who had in utero exposure to the crisis. I find that they are significantly shorter than children who were exposed at later ages. There is a large difference in effect for urban and rural children. This finding helps attribute the detrimental health effects to the crisis and not other events which occurred during the period of analysis. The second chapter exploits the exogenous shock of the crisis to analyse how early childhood height causes later cognitive development. I argue that this question should be analysed using instrumental variables. The results show a large and significant effect of early childhood height on cognitive ability and the use of instrumental variables changes the results significantly compared to OLS with or without fixed effects. Lastly, I analyse how on the job promotions of British civil servants affect health. In a cross-section, the direction of causality is almost certainly two-way. I argue that the use of individual fixed effects will alleviate this concern. The results show a large, positive effect of a job promotion on health in the subsequent survey phase.