This study focuses on the practice component of United Kingdom (UK) pre-registration nurse education. In particular, the research has concentrated on one school of health - part of a larger higher education institution, in the UK and has explored how the institution ensures the quality of the practice component of two of its pre-registration nurse education programmes, the Adult and Mental Health branch programmes. A ‘Major Review’ inspection of these programmes was undertaken in 2005 as part of the requirement of the Quality Assurance Agency (QAA) (2001). The research analysed whether the precepts that relate to the practice component of the school’s pre-registration programmes were being implemented, enacted and experienced by those engaged in them. To achieve this Yin’s (2003) qualitative case study approach was adopted, involving interviewing senior lecturers (n=9), mentors (n=7) and student nurses (n=8) and undertaking in depth analysis of relevant documentation. The findings identified that the precepts themselves did not directly influence what the link tutors and mentors did. As a result, the student nurses experienced different levels of support from link tutors and mentors. This prevented students from experiencing a standardised approach to the practice component of the programmes studied. From this it has been concluded that the ethos of the Major Review process has had no long term impact with regards to standardising and quality assuring the practice component of the programmes studied, a finding that has not been formally reported elsewhere. Instead individual values, beliefs and practices dominated the way in which the players studied operated. The study also highlights how broad and non-descript the precepts themselves are in guiding the school towards a standardised approach to the practice component of the programmes in question. All but one of the precepts ‘Staff Development’ were evidenced as being implemented and/or experienced. Having researched the placement learning precepts (QAA 2001) in their entirety, which has never been done before, it became evident that whilst the content of all of the precepts had been included in the documentary data studied (Clinical Assessment of Practice Documents, School Plan and Pathway Guide), this did not guarantee that all of the precepts were fully implemented and enacted by relevant players. This was because the instruction and guidance within the documents studied were often broad and non specific, to which the design of the precepts allowed. The outcome of this enabled a) link tutors to interpret their roles and responsibilities in different ways; b) theory practice gaps to emerge, which ranged from weak partnership relationships between link tutors and practice placement mangers; c) mentors and link tutors interpreting the CAPD differently and d) mentors mentoring and assessing students in different ways. This resulted in students nursing experiencing different types of learning opportunities and assessment practices that did not always match the learning and development that may be needed in order to practice as a competent and confident registered nurse, at the point of registration. Additionally, there was a lack of understanding by all players about local quality assurance systems and processes. This ranged from none of the participants being familiar with the complaints procedures, or being clear about how placement learning experiences were monitored and evaluated. As a result of these findings the competence of the personnel (link tutors and mentors) studied has been questioned. A phenomenon that highlighted that precept 6 ‘Staff Development’ (which required institutions to ensure that staff who are involved in placement learning are competent to fulfil their role), was not being demonstrably implemented or enacted. A series of recommendations have been designed to meet both the needs of the school studied and others similar. Some of the recommendations relating to the school studied have already been implemented with positive effect. This was evidenced when the researched school was confirmed as having an ‘Outstanding Level of Achievement’ for practice learning following a more recent quality assurance inspection by HLSP on behalf of the Nursing and Midwifery Council.

Lumbopelvic pain (LPP) is associated with altered abdominal muscle function yet few tools exist that enable physiotherapists to identify these changes in a clinical setting. Ultrasound imaging (USI) has potential however its ability to detect altered abdominal muscle function and associated changes in bladder base (BB) position during tests common to a physiotherapy assessment of LPP, has yet to be established. The aims of this research were to determine the validity and reliability of USI technique in a clinical setting, investigate the relationship between changes in abdominal muscle thickness and electrical activity, and compare sonographic characteristics of the abdominal wall, and BB position, between persons with and without LPP. Validity results indicate that 5o-10o of angular, and 8mm of inward/outward transducer motion don’t produce measurement error, and that transducer motion can be kept within these thresholds during two commonly used clinical tests; the Active Straight Leg Raise (ASLR) test and Abdominal Drawing in Manoeuvre (ADIM). Regarding reliability, measurements of abdominal muscle thickness, inter-recti distance (IRD) and BB position (healthy and LPP cohorts) during the ASLR and ADIM were good to excellent (within day ICC; 0.84-0.99, between day; 0.80-0.99). Crosscorrelation functions examining the relationship between changes in abdominal muscle thickness and activity during an ASLR and ADIM were low (r=0.22-0.40), and associated time lags large (-0.44-1.15s), suggesting that changes in muscle thickness represent more than changes in electrical activity. On comparing sonographic features between cohorts a series of features were identified that differed between the groups. Specifically, the LPP cohort had a thinner rectus abdominis (p<0.001), thicker perimuscular connective tissue (p=0.007), a wider IRD (p=0.005) and demonstrated smaller increases in TrA thickness (p≤0.00-0.05), and greater BB descent (p=0.02-0.03) during the ASLR. To determine if these sonographic features assist in discriminating LPP a statistical classification technique was piloted. Preliminary results identified a set of 14 sonographic features that classified LPP participants with 84% accuracy. These findings support an argument regarding the clinical value of USI and serve as the basis for future investigations aimed at determining if USI enhances the assessment, and ultimately treatment, of individuals with LPP.

Mobility in later life can take various forms, as a result of changes in personal circumstances, such as physical impairments and driving cessation. Therefore, understanding the concept of mobility in later life is complex and challenging. Through an interdisciplinary qualitative approach, this thesis examines the role of information and communication technology in supporting mobility and independence in later life. The research highlights a gap in the theoretical understanding of the concept of mobility, and uses insights from the three thematic areas of transportation, technology and older people, as well as key concepts such as social inclusion and independence, in order to develop a new conceptual framework to study mobility in later life. Research that brings these three areas of transportation, technology and older people together, is largely absent from the study of mobility. The research methodology included two phases of data collection. Firstly, the Mobilisation and Accessibility Planning for PEople with Disabilities (MAPPED) project, which focused on the field trials of tailored handheld navigational devices by older people; and secondly, the Getting Out and About project, which involved older people participating in in-depth semi-structured interviews with hypothetical vignettes. The results highlight the importance of mobility in maintaining independence in later life, whilst recognising the heterogeneity of older people by demonstrating a variety of attitudes, experiences and perceptions towards travel behaviour and information and communication technology in later life. The thesis argues that through the facilitation of virtual mobility, such technologies can offer older people an important alternative to physical mobility, which can be further explored in the future design and implementation of policies aimed at supporting older people and improving their well-being and social inclusion

At least one patient will experience a potentially serious intravenous (IV) drug error every day in an ’average’ hospital. IV drug errors have been estimated to be a third of all drug errors. Previous drug error research has focused on observation of nurses and errors they make but has not attempted to understand the decision-making processes used during the preparation and administration of IV drugs. The aim of this study was to explore the decision-making processes that novice and experienced IV nurses use during IV drug administration and how this influences risk taking and errors. A three-phased ethnographic study was carried out in a specialist cancer hospital, using focus groups, observation and interviews. Three focus groups with 14 registered nurses were used to develop culturally relevant definitions related to error and experience. Observation of the two wards took place over a week each. Twenty nurses were observed preparing and administering IV drugs, and then interviewed about their procedure. Data analysis was carried out using a five stage approach. Definitions of drug error, IV drug error, novice and experienced IV givers were developed from the focus groups. Four major themes were identified and represent findings from the direct observation and interview of the nurses: interruptions; lack of identification/knowing the patient; routinised behaviour; prevention of errors. One of the key findings was the lack of checking of patient identity prior to IV drug administration, which appeared to be based on the nurses feeling they knew the patient well enough although this was in contrast to the checking of drugs even if they were familiar with them. Implications for practice included: exploring new and effective methods of education based on behavioural theories; involving staff in updating and writing policies and procedures; and formal assessment of staff during IV preparation and administration.

It is argued that healthcare governance should play an important role in the overall functioning and effective performance of hospitals. However, the literature is devoid of how healthcare governance influences the performance of hospitals in Africa and other developing countries. This study examines the effects of hospital boards and ownership structure on the performance of hospitals in Ghana. The study specifically examines the characteristics of hospital boards, ascertains whether the presence of a hospital board and ownership structure affect hospital performance, evaluates the effects of hospital board characteristics and ownership structure on hospital performance, and also investigates the interaction effects of hospital board characteristics and ownership on performance. Based on a sample of 132 hospitals, the study produces a number of results. First, the study indicates that 69% of the hospitals have a board in place. The results also show that all the mission hospitals have a board in place. Half of the public hospitals and 80% of the private hospitals also have a board. The hospitals with a board exhibit varying board characteristics. Using regression models, the results show that hospitals with a board demonstrate lower occupancy, higher discharge and deliver better quality healthcare. In terms of the effect of board characteristics on performance, smaller boards are associated with better health service quality and lower occupancy. Hospitals with greater proportion of outside board members assist management to be cost efficient and improve on their operations leading to higher discharge. The results also show that hospitals with greater representation of medical staff on the board perform better in terms of occupancy but are less cost efficient. Hospitals with CEO duality perform better in terms of efficiency. However, hospitals with separate positions for the CEO and chair perform better in terms of discharge and service quality. Additionally, the evidence suggests that boards with higher female representation deliver better quality of healthcare, resulting in higher discharge rate. Also, frequency of board meetings is associated with lower occupancy, higher discharge and improved health service quality. The results also show that mission-based and private hospitals perform better than public hospitals. Further, the results of the interaction effects suggest that mission-based and private hospitals with effective board governance exhibit better performance than public hospitals. This study makes a number of new and meaningful contributions to the extant literature and the findings support managerialism, stakeholder and resource dependency theories. The findings also have important implications for effective and efficient governance and management of hospitals.

This thesis explores the appropriateness of suitably trained children's nurses undertaking the pre-operative assessment of children prior to day case and minor surgery. The central focus of the study is a 60 subject hypothesis refining randomised controlled trial (RCT), comparing the pre-operative assessment of children carried out by suitably trained nurses with the assessment carried out by senior house officers (SHO's). Findings demonstrate significantly greater accuracy by nurses in the detection of abnormalities in children's history, when compared with the SHO's. No significant difference is demonstrated between the performance of nurses and SHO's in detecting abnormalities within the physical examination, or in the correct identification of children who have no detectable abnormalities. However, these findings of 'no significant difference' must be substantiated within a larger equivalence trial before assurances can be given that paediatric pre-operative assessment might safely be transferred from SHO's to nurses. Supplementary data explores the perspectives of parents and practitioners with regard to children's nurses undertaking a pre-operative assessment role. The views of parents, gathered via questionnaires, are supportive of the initiative. The views of nurses and SHO's involved in the RCT are similarly supportive, although the conduct of in-depth interviews with the nurses also reveals insights into their perceived vulnerability when carrying out such expanded roles. The views of anaesthetists are less positive, and convey a reluctance to accept nurses carrying out the pre-operative assessment of children. Finally, a national survey explores the views of nurses and SHO's involved in paediatric pre-operative assessment, revealing that nurses attribute significantly greater importance and enjoyment to the pre-operative assessment role when compared with SHO's. This factor may in part explain the greater accuracy demonstrated by nurses in the RCT, but such speculation must be substantiated by further enquiry. This study contributes to the nursing literature in offering what is thought to be the first systematic UK exploration of the role of the paediatric nurse within pre-operative assessment. It is also the first study, as far as the author is aware, to demonstrate significantly greater accuracy in history taking by nurses when compared with doctors, in a paediatric specific UK study. It therefore makes a meaningful contribution to both the paediatric and expanded role evidence bases. It also offers systematically informed hypothesis generation to underpin the ongoing exploration of an expanded nursing role within paediatric pre-operative assessment.

This study was carried out in response to the policy attention directed at older people discharged from hospital with ill-defined conditions, or signs and symptoms related disease. In England there has been an increase in incidence of this type of hospital admission and policy suggests that patients with these codes have fewer medical/physiological and more ‘social’ conditions that could be better managed in community settings. Currently however, this population has not been characterised. Description of the functional and physiological status of these patients is essential for the planning of future health and social care services. Patients with ill-defined conditions were described via a cross-sectional study of 80 patients aged over 70 years admitted to hospital with collapse/falls. Number of chronic diseases and prescribed medications were obtained from the medical records. Routine blood tests were taken and serum cytokine concentrations (IL-1β, IL-6, TNF-α, IFN-γ) were measured. Deprivation score, functional status, depression and the prevalence of frailty were ascertained. 35 patients received ill-defined condition codes, 45 received other codes. Patients with ‘illdefined conditions’ had normal routine blood results but very high serum concentrations of pro-inflammatory cytokines which did not correlate with number of chronic diseases indicating considerable medical problems. As the policy had suggested, they also had prevalent functional impairment (65.7%), high rates of frailty (77.1%) and pre-frailty (14.3%), and depression (42.9%). Patients with ill-defined conditions had poor outcomes evident in the high readmission (60%) and mortality (20%) rates. Patients were hospitalised for a statistically significantly shorter period than patients with other codes (p<.05) and functional limitations and depression were associated with a longer length of stay. Increasing deprivation and TNF-α concentration were associated with an increase in the odds of an illdefined condition diagnosis at discharge. The association between functional limitations, frailty, chronic disease and depression add considerable complexity to the health of older people with ill-defined conditions. However, the prevalence of multiple morbidity, high serum concentrations of inflammatory markers and poor outcomes indicate that they also have considerable medical problems that may be largely unmet. These medical problems may result from chronic disease symptom crises and manifest as geriatric conditions for which there are no appropriate International Classification of Diseases (ICD-10) codes. The results of this study indicate a need for reevaluation of the ICD-10 system to incorporate the health problems faced by older people and further research into the effect of a more comprehensive community-based chronic disease management that aims to enable frail older people to maintain health and independence at home and prevent readmission in patients with ill-defined conditions.

Chronic neck pain can occur in a proportion of individuals who have suffered a whiplash injury and also in individuals that have not experienced a trauma to the neck. The mechanisms that cause chronic pain are unclear, and whether they differ in traumatic or non-traumatic onset is unknown. A review of the background literature identified differences in muscle activation for individuals with chronic neck pain, following a whiplash injury and from a non traumatic onset, compared to healthy controls. However, differences in the combined action or synergy of superficial neck muscles in these chronic neck pain groups, during non-forced activities, had not been widely reported. A new methodology was developed to address this area of research. A pilot study was undertaken to establish the reliability of the method and to identify areas for refinement. The main study employed the refined methodology to determine possible differences in activation and synergies of the upper trapezius and sternocleidomastoid muscles, alongside correlations of subjective pain and fatigue with surface electromyographic measures, using linear array electrodes. Some differences in muscles activation and synergy were observed between the groups. Individuals showed different strengths of relationships between subjective and objective measures and different proportions of significant correlations were shown between groups.

Introduction: Clinical Leadership is a way of facilitating change and increasing the quality of care at the front line of practice. However, the failure of midwifery leadership and being designated an oppressed group questions the ability of midwives to practice as clinical leaders in the labour ward environment. Whilst there is some research relating to clinical leadership in nursing, no research exists that investigates the clinical leadership of midwives who are directly involved in giving care to women. Aim: The aim of this research was to explore clinical leadership on the labour ward and to develop an understanding of the associated characteristics of clinical leadership. The attributes that delineated effective clinical leadership were examined in addition to associated professional discourses and relationships of power that existed on the labour ward. Methods: A critical ethnographic approach was undertaken on the labour ward of a district general hospital and a teaching hospital in the North of England, using participant observation and semi-structured interviews. A total of sixty-nine hours of participant observation was undertaken. A purposive sample of 30 midwives were interviewed in the first instance and further interviews were undertaken with 18 midwives who were nominated as effective clinical leaders by the midwives in the initial interviews. Data were examined through the lens of Bourdieu’s Theory of Practice. Findings: Clinical leadership existed at different levels on the labour ward, however, midwives mostly identified LWCs in this role. LWCs’ clinical leadership was necessary, contradictory, gendered, socialised and unsupported within the hierarchical, high-risk and fearful labour ward. A combination of heroic and values-based clinical leadership was required to maintain safety and facilitate productivity. Heroic leadership, the high level of accountability and symbolic capital invested in the LWC led to a loss of autonomy for other midwives, a lack of dissent and difficulty initiating changes in practice. The contradictory nature of the LWCs’ work and a lack of support led to them experiencing both emotional and physical stress. Within an increasingly highrisk labour ward environment the LWC clinical leaders experienced professional misrecognition and discrimination that resulted in dysfunctional inter-professional relationships and keeping the obstetricians away from women. Conclusion: A high level of responsibility invested in the LWC combined with socialisation led to heroic leadership which fostered dependency prevented change and innovation. Inequalities of power and dysfunctional relationships were symptoms of a system failure that does not support midwifery practice or woman-centred care. Recommendations are made for policy, education, practice and future research.

OLIVEIRA, S. B. Vírus sincicial respiratório humano em pneumonias adquiridas na comunidade em dois anos consecutivos de vigilância (2010 e 2011) em um hospital infantil de Fortaleza. 2014. 66 f. Dissertação (Mestrado em Microbiologia Médica) - Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, 2014. / Submitted by Carolinda Oliveira (ppgmm@ufc.br) on 2017-06-07T12:34:14Z No. of bitstreams: 1 Dissertação Sabrynna Brito Oliveira.pdf: 1150049 bytes, checksum: 97017c28c16ded6006029fc59fc82a08 (MD5) / Rejected by Erika Fernandes (erikaleitefernandes@gmail.com), reason: Corrigir nome do arquivo on 2017-06-07T14:00:45Z (GMT) / Submitted by Carolinda Oliveira (ppgmm@ufc.br) on 2017-06-07T14:07:36Z No. of bitstreams: 1 2014_dis_sboliveira.pdf: 1069633 bytes, checksum: a05458c3bad0f74f614f7e949d8ef1e0 (MD5) / Approved for entry into archive by Erika Fernandes (erikaleitefernandes@gmail.com) on 2017-06-07T14:11:46Z (GMT) No. of bitstreams: 1 2014_dis_sboliveira.pdf: 1069633 bytes, checksum: a05458c3bad0f74f614f7e949d8ef1e0 (MD5) / Made available in DSpace on 2017-06-07T14:11:46Z (GMT). No. of bitstreams: 1 2014_dis_sboliveira.pdf: 1069633 bytes, checksum: a05458c3bad0f74f614f7e949d8ef1e0 (MD5) Previous issue date: 2014-01-17 / The Human Respiratory Syncytial Virus (HRSV) is the leading cause of acute respiratory infection, lower respiratory tract infections in children under five years old viral agent. The example of these infections can quote the Community Acquired Pneumonia (CAP) is the leading cause of death among infectious diseases in this age group. Correct identification of the causative agent of CAP is important for the institution of correct treatment, thus avoiding the misuse of antibiotics and preventing hospital infections. The objectives of this study were to assess the percentage of detection of HRSV in cases of CAP in the city of Fortaleza, Ceará - Brazil, in the years 2010 and 2011 through the immunofluorescence assay (IFA) and polymerase chain reaction preceded transcription reverse viral RNA (RT-PCR), and check for significant differences in the epidemiology and seasonality of HRSV compared the results between techniques. Of the 483 samples of CAP, 195 (40.37 %) were diagnosed in 2010 and 288 (59.63 %) in 2011. Of the total, 55 samples (11:38 %) were positive for HRSV by IFA technique and 97 (20.8%) by RT - PCR. A significant increase of 43.29 % in total samples positive for HRSV by RT-PCR when compared to the IFA technique (p = 0.0000). RT - PCR showed a sensitivity, specificity, agreement and positive and negative predictive value of 94.54 %, 89.48 %, 62.82 %, 53.60 % and 99.22 % respectively. It was observed that HRSV did not follow the same seasonal pattern when comparing the years 2010 and 2011. Positive cases 2011 occurred mainly in the months of March and April , three months before the 2010 positive cases , which occurred in the months of May, June , July and August (p = 0.0000). It was observed that the peak positive was correlated with the rainy season, but not necessarily all peaks of rainfall of the year in which the positive and even between both techniques showed peaks at different months. The occurrence of HRSV in Fortaleza showed a seasonal pattern associated with the rainy season for both techniques. The RT -PCR was more sensitive in detecting cases of CAP caused by HRSV compared to the IFI , enabling better identification of the viral agent and allowing a better characterization of the extent of the epidemic virus periods. / O Vírus Sincicial Respiratório Humano (VSRh) é o principal agente viral causador de infecções respiratórias agudas do trato respiratório inferior em crianças de até cinco anos de idade. A exemplo dessas infecções pode-se citar a Pneumonia Adquirida na Comunidade (PAC) que representa uma das principais causas de óbito entre as doenças infecciosas nessa faixa etária. Os objetivos desse estudo foram verificar o percentual de detecção de VSRh em casos de PAC na cidade de Fortaleza, Ceará – Brasil, nos anos de 2010 e 2011 através das técnicas de imunofluorescência indireta (IFI) e da reação em cadeia da polimerase precedida de transcrição reversa do RNA viral (RT-PCR), além de verificar se há diferença significativa na epidemiologia e sazonalidade do VSRh quando comparados os resultados entre as técnicas utilizadas. Das 483 amostras de PAC, 195 (40.37%) foram diagnosticadas em 2010 e 288 (59.63%) em 2011. Do total, 55 amostras (11.38%) foram positivas para VSRh pela técnica de IFI e 97 (20.08%) pela técnica de RT-PCR. Houve um aumento significativo de 43.29%no total de amostras positivas para VSRh por RT-PCR, quando comparado com a técnica de IFI (p=0,0000).A RT-PCR apresentou sensibilidade, especificidade, concordância e valor preditivo positivo e negativo de 94.54%, 89.48%, 62.82%, 53.60% e 99.22% respectivamente. Observou-se que VSRh não seguiu o mesmo padrão sazonal quando comparados os anos de 2010 e 2011. Os casos positivos de 2011 aconteceram principalmente nos meses de março e abril, três meses antes dos casos positivos de 2010, que ocorreram nos meses de maio, junho, julho e agosto (p=0,0000). Observou-se que o pico de positividade esteve correlacionado com o período chuvoso, mas não necessariamente com todos os picos de chuvas do ano correspondente e ainda que a positividade entre as duas técnicas apresentou picos em meses distintos.A ocorrência do VSRh na cidade de Fortaleza mostrou um padrão sazonal associado ao período chuvoso por ambas as técnicas. A técnica de RT-PCR mostrou-se mais sensível na detecção de casos de PAC por VSRh quando comparada à IFI, possibilitando uma melhor identificação do agente viral e permitindo uma melhor caracterização da extensão dos períodos epidêmicos do vírus.