Hand hygiene is considered the cornerstone of infection prevention practice, but previous studies demonstrate one group of healthcare professionals, doctors, have not achieved good levels of compliance in comparison to other staff groups. The aim of the research was to examine consultant doctors‟ practice and perspectives of hand hygiene, exploring their perceptions as leaders and role models, so as to identify strategies to improve compliance. The study design was based on naturalistic inquiry, focussing on the social constructions of participants. Nineteen consultant doctors were observed during hospital ward rounds using both a national audit tool to assess hand hygiene compliance and recording of field notes. These same consultants, plus a further two, were interviewed individually to elicit their views. Data from the 21 interviews and field notes were analysed qualitatively using thematic content analysis. Observations demonstrated high levels of hand hygiene compliance for high risk and medium risk activities, with low levels of compliance for low risk activities. Thematic content analysis revealed a strong belief by consultant doctors in the value of hand hygiene. However, a perceived conflict between political and scientific drivers of hand hygiene promotion gave rise to confusion, frustration and a lack of engagement that created barriers to leadership and acting as a role model. Differing guidelines and audit tools that did not address levels of risk compounded the matter. However, consultant doctors offered various recommendations to resolve the issues. Compliance with hand hygiene by consultant doctors is dependant on perceived levels of risk. To promote leadership and role modelling it is critical to engage consultant doctors, understand their views, employ their recommendations and recognise they are motivated by evidence-based rationales for practice rather than political mandates. The findings, conclusion and recommendations of the research study have significant implications for addressing the shortfalls of the hand hygiene agenda in clinical practice and for the engagement of consultant doctors.

Cochlear implants (CI) provide a sense of hearing to people who are severely or profoundly deaf. A single CI (unilateral) has been shown to improve quality of life (QoL) substantially and clinical practice is evolving towards two per patient (bilateral), although the incremental benefit for QoL has not yet been established definitively. There is a need for self-report measures designed specifically to quantify benefits for QoL in patients who receive a second CI, in order to evaluate the relative benefits of unilateral and bilateral implantation. The aim of the present study was to develop and validate such a measure that is suitable for adults. The sample consisted of patients from the United Kingdom National Health Service who have received two CI sequentially. The study was based on the ‘Rolls Royce’ approach. A retrospective open-ended questionnaire and face to face interviews were carried out in the first stage. Categories from the qualitative data obtained from the responses were identified and these were the foundations on which a close-ended questionnaire was developed. In the second stage, face validity, test-retest reliability and correlations of each item were investigated and amendments were made to the questionnaire items to reflect these results. In the last stage participants were asked to fill in the amended questionnaire together with another three existing QoL questionnaires (generic and disease-specific ones). These results showed that the questionnaire under development is valid and reliable. Responses from the participants also gave an insight into the changes that they experienced as a result of receiving a second CI. The main reports were related to experiences of increased confidence and independence levels as a result of having bilateral CI. Improvement in listening in group situations and localisation ability were also noted. Changes in participant experience were evident when they filled in the questionnaire under development and also the Speech, Spatial and Qualities of Hearing questionnaire. Better understanding of changes in QoL after receiving a second CI will help professionals to understand the benefits of bilateral implantation in adults from the users’ perspectives. This is considered to be important when deciding whether patients should be advised to opt for unilateral or bilateral CI in the future. This knowledge will also help prospective patients understand the practical benefits and limitations of one or two cochlear implants.

This thesis is concerned with the modelling of patient length of stay in public hospitals in Mexico. Patient length of stay is the most commonly worldwide employed outcome measure for hospital resource consumption and performance monitoring. Most of the hospitals around the world use average length of stay as starting point for resource planning. However average estimates frequently gives non-accurate results due to the high variability of the length of stay data. The reason for such high variability may be attributable to the diversity in the patient population and the environment where the patient is treated. Through a systematic review of the literature on methods and models in the field of calculating and predicting patient length of stay, this research highlights the areas of opportunity and research gap from previous studies and practices, and proposes the use of finite mixture models to approximate the distribution of length of stay. Also, these models are proposed as the foundation of more sophisticated models designed to include the internal and external factors associated with LoS. In this context, the thesis proposes three different approaches to explore such factors: individual-based approach, group-based approach and multilevel group-based approach. These interrelated approaches allow a better understanding of the diversity in the patient population and enable length of stay predictions for individual patients, and for cohorts of patients within and between hospitals. In addition, this research is built and evaluated using data from all types of patients treated at two public hospitals operating in Mexico. It is the consideration of the full case-mix of these healthcare facilities that gives this research its unique nature.

Consultant nurse and midwife roles, with the expectations of significantly moving forward the professions in relation to practice development, effective leadership and quality care provision, have been a major UK policy initiative since 2000. Whilst consultant nurses have received much attention, consultant midwives have been relatively little researched. This study aimed to explore the intricacies of the consultant midwife role. Using an in-depth qualitative case study design, the roles of eight consultant midwives across eight NHS Trusts in England were studied. Data were collected via in-depth interviews with consultant midwives, their heads of maternity services and consultant obstetricians; additionally, the consultant midwives were observed in practice and documentary evidence (their job descriptions) were examined. Data were analysed thematically and aggregated, revealing three dominant themes related to clinical wisdom, taking control and shaping the future. Findings showed that the consultant midwife is in a position of power, built on a foundation of clinically acquired wisdom, transformational leadership skills and a belief in woman centred care, essential to a profession fit for the future. Individually and collectively, the consultant midwives conveyed a passion for their role, whilst aware of the demands of their position. Their impact lay in relation to the way they used their experience, skills and understanding, to undertake complex roles in practice, juggling responsibilities to effect change and improve services for childbearing women and their families. Their strength was born out of acquired knowledge and expertise, as leaders and as role models, influencing not only practice but the midwives of the future. This thesis provides the first in-depth exploration of the consultant midwife role and as such greatly strengthens the hitherto limited evidence base. As well as focusing on the particular aspects of day-to-day consultant midwifery it also gives detailed recommendations for further development of the role organisationally.

Older people are the world’s fastest growing population group. By 2050 eighty per cent of older persons will live in what are now developing countries. There is established and growing evidence of the difficulties families in developing countries are experiencing in providing adequate support for their older members. This thesis explores how international development is responding to the interests of older people. The research examines how older people are represented in international development discourse and illustrates the impact of this on practice. This is informed by a comparative analysis with the progress of women in development. A critical discourse analysis of a corpus of texts from intergovernmental agencies illustrates the degree of visibility of older people in the development discourse. A case study of the work of inter-government organisations in West Bengal, India, shows how this can impact on grassroots activity. An original conceptual framework is introduced which aligns the dominant development paradigms with the dominant perspectives on older people emerging from this research. To the best of my knowledge this is the first research study to consider the (in)visibility of older people in international development discourse and to look at its implications on policy and practice. It highlights that a concentration of development resources at one end of the age spectrum to increase life expectancy is being met with an absence of planned support to meet the consequences when people successfully reach old age. The research further shows that when visible, older people are generally viewed as a homogeneous group in need of support and care, and not as citizens able to contribute and participate in development. The research illustrates a connection between global discourse and local practice in relation to older people and indicates a need for further studies to assess the extent of the links and to examine how local practice could inform the international development discourse.

Nursing scholarship and healthcare policy set an expectation that nurses should think about patients as persons. Nevertheless, the literature reveals that critical care nurses can struggle to perceive patients as persons, and thus suggests they may think about patients in different ways. This thesis presents the findings of an ethnographic study undertaken within one critical care unit in the United Kingdom which examined how critical care nurses do think about patients. A purposive sampling strategy recruited 7 participants representing both experienced and inexperienced critical care nurses. Data were collected over a period of 8 months during 2006 to 2007, and primarily comprised the field notes from 92 hours of participant observation supplemented by 13 tape recorded interviews. Data analysis was influenced by Foucault and Goffman and adopted the perspective of linguistic ethnography. Analysis revealed that all participants thought about patients in seven distinct ways: as ‘social beings’, as ‘valued individuals’, as ‘routine work’, as a ‘set of needs’, as a ‘body’, as ‘(un)stable’ or as a ‘medical case’. Accounts of participants’ practice revealed that they had a tacit understanding that these different ways of thinking related to aspects of one coherent whole, but no one way of thinking could be characterised as thinking about this ‘whole person’. Nurses could only think about one aspect of the patient at a time. Nurses’ practice was not guided or explained by their thinking about patients as persons, but rather expert practice was characterised by nurses’ fluid and appropriate movement between different ways of thinking about patients. When participants talked about their practice it was evident that these nurses could only legitimately talk about themselves as giving care to persons. Participants characterised some of the ways in which they had to think about patients as impersonal, and this actively hindered these nurses from describing or reflecting upon elements of their practice. There is therefore conflict and dissonance between nurses’ expectation that they should think about patients as persons, and the fact that delivering nursing care requires them to think about patients in different ways. The development of future critical care nurses will require practitioners and educators to recognise that nurses think about patients in different ways, and that expert practice is characterised by the clinical wisdom which enables nurses to think about patients in ways which are appropriate to the moment. Nurse scholars and educationalists should therefore avoid claims to a unique professional knowledge base which suggest to nurses that some ways of thinking are always inappropriate or inherently reductionist. Instead, there is a need for scholars and policy makers to articulate a vision of person centred care clearly, and in ways which avoid constructing dissonance between nurses’ ideals, and the ways in which they do and must think about patients.

No description available.

Analysis of breathing pattern can quantify parameters of breathing such as rate, volume, timing and regularity/rhythmicity. This information can be useful to compare breathing patterns in those healthy and with disease, under different experiment conditions (such as rest versus activity) and to monitor changes over time. In this research, respiratory inductive plethysmography (RIP) was used to record breathing patterns in a group of healthy subjects and a group of severe asthma patients. RIP is a leading technology for ambulatory monitoring of breathing, but traditional RIP devices suffered from poor signal quality under such conditions due to movement of the sensor. Several authors have also raised doubts about the existing calibration methods for RIP which can lead to inaccurate estimation of breathing parameters. During the first phase of the programme, an instrumented garment (LifeShirt®) which had RIP embedded within was tested for its validity in comparison to a pneumotachograph (PT). The first study sought to validate the measurements obtained from the LifeShirt ®against PT when calibrated with a published but yet to be tested method for breath by breath analysis and to address the limitations of existing calibration methods. Eleven healthy individuals took part in this first study. Breathing patterns were simultaneously monitored by the LifeShirt ® and the PT during thirty minutes of rest and twenty minutes of exercise. Parameters of tidal volume, expiration time and tidal volume variability were recorded and compared between devices. The analysis from the first study demonstrated that RIP recorded proportionate changes of tidal volume and expiration duration relative to PT during quiet breathing and exercise. Mean tidal volume and expiration duration between devices was strongly correlated for rest and exercise. No statistical difference in tidal volume variability was observed between devices during either period. Significant differences in expiration duration between devices were observed in all participants at rest but not during exercise. Results of this first study demonstrated that valid breath by breath analysis using RIP without PT was feasible. This is clinically advantageous due to simplicity of set-up for RIP. In the second phase, measurement of breathing patterns was made in severe asthma patients with the LifeShirt® alone during thirty minutes of rest. It intended to add new knowledge with regards to the breathing patterns within this small population as compared to the healthy population. Ten healthy individuals and ten patients diagnosed with severe asthma took part in the second study. Breathing parameters of tidal volume, inspiration time, expiration time, end tidal carbon dioxide levels, tidal volume variability and end tidal carbon dioxide levels variability were recorded by the LifeShirt®. The analysis of the second phase shown no evidence that breathing pattern parameters could differentiate between the severe asthma patients and healthy volunteers in our small study. The symptoms of hyperventilation found more commonly in the severe asthma group were not associated with differences in breathing pattern parameters. However, considerable differences were found between individuals. This suggests the existence of individuality in breathing patterns between individuals. Such findings raised doubts as to whether there is a group ‘pattern’ that is common within the severe asthma population or within the healthy population. This programme calls for a change in paradigm to consider breathing patterns as an unique individual ‘trait’ rather than as a group characteristic.

This cross-national comparative study aims to explore previous changes and future trends in nursing in England and mainland China, and the impact that reform has had on the way in which nurses are currently and prospectively educated in the two countries. Nursing education in both countries has experienced considerable development related to societal, health care, and technological advances, alongside economic growth. In England, there is a policy imperative to shift nursing to an all-graduate discipline and a need to look at the balance of the health care workforce. In mainland China, there is a goal to educate nurses who are fit for the changing healthcare system, during a period of health care reform which attempts to improve primary health care delivery in rural and urban areas. A case study design has been adopted in two settings, one nursing school in England and one in mainland China. Participants are those involved in the provision of nursing education – the nurse teachers. In-depth data were collected by interviews from 11 people in the English site and 10 in the Chinese site. Thematic analysis was used to analyse the data. These data are set within the historical and contemporary contexts, through an analysis of the literature. Findings indicated that the trajectories of the development of nurse education in the two countries are varied, but with interesting similarities and differences. For example, the professionalisation of nursing in the two countries has followed a pathway that is comparable in some senses but not others. This is related to such issues at the inter-relationship of medicine and nursing and views about the status of nurses. Main conclusions of this study include the increasing emphasis on community care and the linked need for further curriculum development to prepare nurses in both countries for such changes.

Childhood sexual abuse is a major, but hidden public health issue estimated to affect approximately 20% of females and 7% of males. As most women do not disclose to healthcare professionals, midwives may unwittingly care for women who have been sexually abused. The purpose of this study was to address the gap in our understanding of women’s maternity care experiences when they have a history of childhood sexual abuse with the aim of informing healthcare practice. This narrative study from a feminist perspective, explored the maternity care experiences of women who were sexually abused in childhood. In-depth interviews with women, review of their maternity care records and individual and group interviews with maternity care professionals were conducted. The Voice-centred Relational Method (VCRM) was employed to analyse data from the in-depth interviews with women. Thematic analysis synthesised findings, translating the women’s narratives into a more readily accessible form. The main themes identified were: narratives of self, narratives of relationship, narratives of context and the childbirth journey. Medical records provided an additional narrative and data source providing an alternative perspective on the women’s stories. Silence emerged as a key concept in the narratives. This thesis contributes to ‘Voicing the silence’. The particular contribution of the study is its focus on the women’s voices and the use and development of VCRM to listen to them. It highlights where those voices are absent and where they are not heard. Women want their distress to be noticed, even if they do not want to voice their silence. The challenge for those providing maternity care is to listen and respond to their unspoken messages and to hear and receive their spoken ones with sensitivity.