Existing research into leadership has relied on individualistic theories which do not provide a satisfactory understanding of the leadership process, particularly in organisations where focus has moved away from vertical, hierarchical leadership, towards more distributed or emergent models (Avery, 2004; Dess & Picken, 2000; Denis, Lamothe & Langley, 2001). It is assumed that individuals will emerge as leaders, and be viewed as effective, when they are rewarded as prototypical, or representative, of the group they are attempting to lead (Hogg, 2001b; Hogg & Terry, 2000), and when they exhibit stereotypical leadership behaviours (Lord, Brown, Harvey & Hall, 2001a; Offermann, Kennedy, & Wirtz, 1994). To date, research has assumed that the two identity concepts are compatible, with little consideration given to groups whose professional identity is dissonant with expected leadership stereotypes. The question therefore arises: how does professional identity influence ability of individuals to construct a leadership identity, when those identities are orthogonal? To address this research gap I focus on leadership in nursing, a profession who have traditionally been defined by their subordination to doctors (Abbott, 1988; Allen, 1997; Campbell-Heider & Pollock, 1987). Combining real-time participant observation of two leadership development programmes with over 60 hours of longitudinal semi-structured interviews from 32 participants, I provide new insights into the chronic identity conflicts encountered by subordinate professionals, and the identity work they use to overcome those conflicts. Drawing on my analysis I develop a typology of four resulting identity constructions, with differing levels of leadership influence and identity conflict. In doing so I illuminate the processes through which subordinate professionals mediate de-coupled identities, challenging the assumption that the existence of a group identity is always beneficial and complementary to leadership behaviours (Hogg, 2001a), and highlight an arena where it can actually be detrimental to the emergence of a leadership identity.

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General practice has undergone considerable change in the last two decades. New roles for nurses working in general practice have extended to include tasks that were previously delivered by general practitioners, in particular chronic disease management, and the development of new, advanced roles such as independent nurse prescribing. There have been few research studies investigating the impact of these changes, especially after the introduction of the new General Medical Services contract in April 2004. The overall aim of the work presented in this thesis was to examine the emerging roles of practice nurses, the forces influencing that development, and the effects of these changes on doctor-nurse skill mix in general practice within NHS Scotland. The work employed a mixed methods approach, with three inter-linked studies. The first study was a quantitative, desk-based analysis of workload and clinical activities of doctors and nurses working in 37 practices across Scotland for the year 2002. The second study was a postal questionnaire to all practice nurses working within NHS Greater Glasgow (n=329), conducted in autumn 2005 and achieving a 61% response rate. The third study was a qualitative study, consisting of eighteen interviews with a doctor and nurse inform each of nine general practices. The interviews were conducted between January and July 2006 and practices were selected according to the number of partners and the deprivation status of the practice population. Analysis of workload data showed that practice nurses and general practitioners dealt with 27.5% and 72.5% of total face-to-face encounters, respectively. Many of the encounters with nurses involved chronic disease management, with 20% of such encounters appearing similar in content to the work of GPs. The postal survey found that one third of practice nurses were aged over 50, and will be approaching retirement within 10 years. The majority worked in small teams of nurses, although 31% worked alone. This may have contributed to the finding that 52% (n=103) reported feeling isolated in their workplace. Many had attended CPD training on chronic conditions, but identified minor illness treatment as an area for future training. The qualitative study showed that the Quality and Outcomes Framework of the 2004 contract had been a key driver of changes in general practice service delivery. This has led to an increasing shift in routine care from doctors to nurses. As new roles for practice nurses have evolved, GPs have been able to focus on treating complex morbidities that need medical diagnosis and intervention. The incentivised targets of the new contract have made chronic disease management a predominant activity for practice nurses, with treatment room and non-incentivised activities featuring less and increasingly being provided by new, lower grade nurses or nurse replacements such as Health Care Support Workers (HCSW). There was no consensus between interview participants in terms of the most appropriate use of doctor-nurse skill mix in general practice. Nor did they agree on the merit of advanced roles for practice nurses. However, respondents did emphasise that nurses who wanted to have an independent/advanced role in the practice would need to combine three competencies (independent nurse prescribing, triaging, and minor illness treatment). Most practice nurses interviewed were concerned with obtaining a fair financial return to match their increasing responsibilities, especially after the introduction of the nGMS contract. GPs, however, tended to believe that nurses were appropriately remunerated for the level of responsibility they had within the practice. The continuing role of the GP as the employer of practice nurses was problematic for some nurses and many felt there would be advantages to being employed on Agenda for Change terms and conditions. However, the majority of nurses interviewed preferred being employed by a GP rather than the Health Board. There was little support amongst either nurses or GPs for the notion of nurse partners within practices. Overall, these studies provide lessons which will be of value in planning the future training and development of practice nurses. It suggests that practice nurses should obtain proper training and support in order to meet their individual needs and to carry out new responsibilities and roles. In addition, the impending shortage of practice nurses due to retirement, lack of retention and potential recruitment difficulties needs to be addressed urgently at the level of primary care policy and manpower planning.

This study explored the experience of patients with generalized anxiety disorder (GAD) undertaking a six week intervention of a Zen meditation programme in Taiwan. Mix-methods were used including the Revised State and Trait Anxiety Inventory (RSTAI), repeated focus groups, individual interviews, diaries and field notes. Heidegger’s interpretative phenomenology was adopted as a theoretical framework. Two groups of 9 and 12 patients (n=21) participated in the study. Three themes emerged from repeated focus groups: First ‘Expectation of Zen meditation regarding GAD symptoms included sub themes of ‘ambivalence towards meditation’, ‘crave a good sleep’, ‘stop thinking’ and ‘regain memory and concentration’. The second theme, ‘The process of Zen meditation’ included the sub themes of ‘struggling to reach a state of calm’, ‘signs of improvement’ and ‘an individual process’. The last theme, ‘The cultural beliefs regarding Zen meditation in Taiwan’ involved the ‘spiritual influence’ of Zen meditation practice. Four themes emerged from individual interviews. Firstly, ‘Separation’ referred to the issues that participants faced in dealing with the termination of the programme, including ‘concern about other participants’ and ‘examining the relationship between Zen meditation and self’. The second theme ‘Body experience of Zen meditation practice’ incorporated ‘body awareness’ and ‘preparing to practise Zen meditation’. The third theme, ‘States of mind while meditating’ consisted of ‘the state of engagement with real life’, ‘the state of detachment from real life’ and ‘the state of calm’. Lastly, ‘Benefits of Zen meditation practice’ incorporated the categories ‘less pressure with daily life’ and ‘more acceptance of being a GAD patient’. The RSTAI was administrated at baseline and post intervention and also at the two week follow-up of the Zen meditation programme. Neither the Trait Anxiety Score nor the State Anxiety Score showed significant differences between Groups 1 and 2 at baseline. This allowed the RSTAI data from the 2 groups to be merged.The results of 95% confidence interval for differences of both groups showed a significant improvement in the Trait Anxiety Score over time but not the State Anxiety Score. This study contributes to the existing body of knowledge and associated literature regarding Zen meditation and GAD in three ways. Firstly, the findings confirmed that the essential or authentic traditional qualities of meditation should be addressed in meditation study. Secondly, the meaning of Zen meditation for the groups of GAD patients was revealed in the context of Taiwan society. How their lived experience of GAD shaped their understanding of Zen meditation was interpreted. Thirdly, a comprehensive understanding of Zen meditation is reported. The findings (including themes, i.e. diverse Zen meditation processes, body experiences, concepts of obstacles and spiritual influence) add to the current knowledge by providing insight derived from participants’ lived experiences.

The primary focus for this Thesis is an account of the degree to which nurses and other stakeholders in one National Health Service hospital Trust have responded to the ‘clinical governance’ initiative, the effects on quality improvement and professional regulation and the practical accomplishment of legitimacy. ‘Clinical governance’ involves demonstrating that quality assurance is routine practice within every healthcare organization. A case study was undertaken, using broadly ethnographic methods. The qualitative data were obtained by documentary analysis, non-participant observation of meetings and day-to-day ward activity and semi-structured interviews. In terms of the analysis of documents and observation of meetings, new institutionalism theory was found to be useful as a framework for understanding the political and ceremonial conformity that marked the clinical governance process. Errors and inconsistencies were found in formal documentation and the Trusts’ reporting systems were fraught with problems. Nevertheless, during the same period the Trust obtained national recognition for having appropriate structures and systems in place in relation to clinical governance. A grounded theory approach was adopted in the analysis of the semi-structured interviews. Emerging themes from interview data were identified under the main categories of: ‘Making Sense,’ ‘Knowledge Construction,’ ‘Somebody Else’s Job’ and ‘Real Work.’ It was concluded that at a practice level, clinical governance was poorly understood and that the corporate organizational goals were ambiguous and seen as unrealistic on a day-to-day basis. The study concludes that what is happening is not a ‘failure’ but an unintended consequence that has resulted from an inadequate understanding of how organizations work. It is suggested that the organization has conformed to the appropriate standards in order to survive legitimately, but the ultimate impact of clinical governance on the quality of care in practice is inconsistent.

The research study aspired to ascertain what, if any key factors can be identified by the Senior Nurses in Wales to improve the quality and safety of the service delivered by the nursing service. Numerous reports with recommendations for improvement have been published following significant service failures in the nursing service. Despite these reports, failures continue. This thesis details the methodology and findings of a research study undertaken with Senior Nurses in Wales, to ascertain their views on what factors are needed to have a successful nursing service. It explores what needs to be in place in the nursing service to prevent failure and deliver high quality, safe care to patients. A mixed-method research approach was used which comprised three stages. Stage one analysed secondary qualitative data in the form of case study inquiry reports into service failures. The second stage comprised semi-structured elite interviews with nine Senior Nurses in Wales. The final stage, which was used to prioritise and validate the results from stage two, was a questionnaire sent to 65 Senior Nurses in Wales, with 41 returned. From the analysis of the above research, a Senior Nurses’ Framework covering 6 main themes and containing 35 key factors was developed, which if implemented could potentially lead to a successful nursing service. In addition the thesis explores why Senior Nurses find it difficult to implement such actions, their lack of empowerment and how it is important for their voices to be heard if failure is to be prevented in the future.

Reframing Emotional Intelligence as Emotional Wisdom: This research has investigated the motif of emotional wisdom (EW) within a group of female nursing students in one United Kingdom (UK) University, through my perspective as a nurse educator. The provision of effective quality nursing care according to the DOH, (2012) Compassion in Practice policy document identified six fundamental values of nursing: care, compassion, competence, communication, courage and commitment. Nursing practice is predicated on the presence of nurse education that is directed towards developing a safe and competent practitioner. Henderson (2001) and De Lambert (1998) have stated that nursing practice cannot be separated from the affective state of the nurse carrying out nursing care. The nursing literature suggests that EI has a role to play in nurse education, (Cadman & Brewer, 2001, McQueen, 2004, Freshwater & Stickley 2004), a role that is possibly underplayed. Using a qualitative research methodology grounded on a partnership based heuristic, [which is an adaptation of Moutakas’s (1990) methodology]; the study seeks to understand the lived experience of emotional intelligence (EI) of both myself as a nurse educator and those of nursing students. It suggests that a more meaningful way to apply EI within the context of learning and developing as nurses is as emotional wisdom (EW). Aim: to explore the lived experience of EI amongst a group of student nurses Method: a qualitative exploration drawing on Moustakas (1990), which holds the experiences of myself as the researcher, alongside the experiences of a group of nursing students as central to understanding what it is like to be an emotionally intelligent nurse. Findings: the data analysis uncovered four main themes relating to the lived experience of EI among us as a research group: Confronting the Nemesis of Kinsfolk Legacy. This focused on the impact of past emotional events in the development of the study participant in shaping her current emotionally intelligent identity Apprehending the Affective Learning Spaces. This theme explored the learning of emotions and emotional management of self and patients within the ‘classroom’ and the clinical setting pointing to a learning gap between those domains, which was rooted in a lack of emotional preparedness in the university. Authenticity of Being: Occupying Two Worlds. This explored the two domains in which the neophyte nurse found herself coming to an understanding and negotiated role clarity as to whom she was whilst learning as a nurse student and who she was as a daughter, mother, partner. Being Fully Present. This theme explored the data around the experience of learning to be emotionally attuned, or attentive to the patient. These findings are discussed within a creative synthesis and a summary of learning from the study. This seeks to proffer a potential model through which emotionally wise learning might be mediated within nurse education to future nursing students. In presenting such however, I am also offering up these findings with an invitation to you as the reader to determine if your own experiences find resonance with these accounts. Possible implications of the study within the field of nurse education: • Discussion concerning the use of EI measures as an additional recruitment marker to nurse education programmes • A pedagogical approach to nurse education predicated on an EW curricula • Recognition of an ontological oriented curricula in nurse education as a means to enhancing self-awareness.

Aim: Investigated the use of granulated sugar in the management of sloughy, necrotic and infected exuding wounds. Method: The investigation followed the Medical Research Council (MRC, 2007) framework for investigation of complex interventions. Pre-clinical: The study was registered with MHRA, followed by development and design of the mode of sugar delivery to patient use. Evidence review: A systematic review and meta-analysis concluded that there was no existing good quality evidence to support the routine use of sugar dressings. Phase I: Laboratory studies found that all three sugars showed relatively equal activity against all the bacteria tested although Demerara sugar was slightly less active. Phase II: A feasibility study of 22 patients concluded that both insulin and non-insulin treated diabetic patients can be treated with sugar dressing without affecting their blood sugar levels. Phase III: A randomised controlled trial failed to recruit the intended numbers and final analysis was carried out on 22 patients randomised to sugar and 19 randomised to usual care. 19 (86%) achieved debridement at 4 weeks in the sugar group compared to 6 (32%) standard care group (Fisher’s exact test: p<0.001). Overall conclusion: Sugar has an effect on micro-organisms and can be used in modern hospitals and community settings.

This longitudinal study explored the experiences of six dyslexic nursing students, in their final six months of their nursing course, re-visiting them again in their first six months as registered nurses. The study also explored the experiences of those who support them from student nurse to registered nurse, namely their tutors and their mentors and preceptors in practice. A semi-structured interview method was used to interview each participant additionally adopting an iterative interview method. An interpretative case study design was adopted for this study using interpretative phenomenological analysis to analyze the data. The nursing students expressed degrees of negative self-perceptions of themselves, some carried these negative self-perceptions as registered nurses. Some of the mentors, tutors and preceptors lacked knowledge and understanding of dyslexia with some expressing concerns over the safety of a nurse with dyslexia in practice. The results presented evidence of a dyslexic self-stigma and the fear of others perceptions surrounding dyslexia amongst the nursing students, but also evidence of a full acceptance of dyslexia amongst some of the nurse participants. Dyslexia was perceived differently amongst the tutors and preceptors showing a positive understanding amongst some, but also that dyslexic is misunderstood and linked to concerns surrounding patient safety.

This research explores professional identity formation amongst occupational therapy students. Professional identity is examined within an occupational science framework. Much has been written, in recent years, about the professional identity development of occupational therapists during the first stages of their career focusing on preceptorship (Morley, 2006, Tryssenaar, 1999) but the concept of initial professional identity formation remains under examined. This thesis addresses that gap by following one student’s journey of becoming an occupational therapist from enrolment to graduating on an undergraduate occupational therapy course. Five in-depth interviews were carried out over three years. This was situated against a series of focus groups drawn from the same cohort. The Kawa model (Iwama, 2006) was used as a data collection and analytical tool. Three overarching themes which highlight the processes involved in professional identity formation, were identified • Establishing occupational coherence; the participants needed to make sense of their occupational history. It was important for participants to explain and present themselves as having developed occupational coherence over time. • Managing occupational adaptation; the participants dealt with many challenges as they coped with transitions and a changing sense of self. It was important that they developed agency and feelings of competence on their professional journey. •Developing a new identity; the participants explored how they adapted to new possibilities as they experienced the doing of occupational therapy. Their new occupational identity was congruent their own personal values. This interpretative phenomenological analysis makes a significant contribution to the small body of knowledge around professional identity formation in occupational therapy. The longitudinal approach created a nuanced narrative which expounds the complex ongoing process. It highlighted the importance of paying attention to the processes of doing, being, belonging and becoming. The fundamental importance of enabling students to develop an occupational perspective to understand their developing professional identity is identified.