Within secondary care hospital settings, acutely ill patients are exposed to the unnecessary risk of the adverse consequences and increased mortality that arise from suboptimal care. A causative factor of suboptimal care is the level of competence of practitioners caring for the acutely ill patient in their failure predominantly, to monitor, recognise or respond appropriately to the deteriorating patient. In partnership with local healthcare organisations, the acute illness course, on which this study was based, was conceived and implemented. The aim of the course was to provide an academic and clinical experience that focused on the development of skills and competence of post-registration practitioners within non-critical care settings. The first cohort commenced their course in 2006. This study investigated the development of this experience, focussing on students’ skills and competence following their exposure to a variety of teaching, learning and assessment strategies that had been employed. Competence is one of the most commonly used words in healthcare education yet it is a nebulous concept that is defined in diverse ways by different people. The concept of competence provided the theoretical framework that was analysed and applied within the field of acute care. An educational evaluation using a case study approach was used employing interviews for data collection purposes. The case study examined the many variables of interest within the student experience while maintaining a continuous interaction and dialogue between the theoretical and conceptual dimensions that were being studied. This inquiry opened by interviewing former students of the acute illness course. The aspects that were explored included, students’ characteristics, motivations and perceptions of the teaching, learning and assessment methods they had encountered. Of particular interest was the influence of these on the students’ development in clinical practice. Triangulation was adopted through interview data derived from both the former students and their managers. The study critically analysed the principle dynamics that influenced students learning in academic and practice settings. The findings demonstrated the intricate synergies that comprised this exercise in professional development. Motivation, emotional responses and performance were often influenced by the experience. The eclectic mix of learning methods that were used were thought beneficial by the study participants, who found that both the theoretical and the clinically related content of the course to be entirely relevant to their clinical practice. The study established that choice, facilitation and feedback through mixed learning and assessment methods leads to confidence and empowerment that positively influence registered nurses’ competence in clinical practice. It concluded that in this case, practitioners’ continuing professional development was influenced by interlocking concepts that supported the acquisition and maintenance of both their confidence and competence and as a consequence, stood to improve the care of acutely ill patients.

This study critically explores how Bourdieu’s (1985; 1989) concept of social space impacts on the experiences of medical and nursing students in the primary care setting when non-formal work based learning (WBL) is used as a model for interprofessional education (IPE) (Moore, 2012). Current ways in which professionals conduct their relationships with each other are also examined and factors that impede collaboration are also explored using Bourdieu’s theory of social life (1979; 1985; 1989; 1992; 1996; Bourdieu & Wacquant, 1992) as a theoretical lens. Bourdieu (1979) uses the concept of social space as a means of exploring power and hierarchical relationships arguing that social space influences relationships so that whilst groups of people can be located in the same physical space, they can remain socially distant (Bourdieu & Wacquant, 1992). In the United Kingdom (UK) different professions are now located together, within GP (General Practitioner) Practices, in the belief that it will enhance CP (DH, 2005; Hudson, 2007). However, there are a number of factors influencing how doctors and nurses work together and these include the powerful position of the doctor in relation to the nurse (for example: Coombs & Ersser, 2004; Davis, 2003; Fagin & Gaerlick, 2004, Malloy et al 2009, Vogwill & Reeves 2008). Therefore, students placed in this environment are likely to be immersed into practices where power relationships occur and supervised by those who are involved in them. As such it is likely that they learn the implicit, hierarchically influenced, rules of engagement that are practiced by their qualified counterparts (Collin et al., 2011). The study drew on critical ethnographic principles and took place in a city in the north of England. Participants were selected purposively and were comprised of the staff from three GP Practices, as well as medical and nursing students who were on or had recently completed a clinical placement at one of the three Practices. Data were collected predominantly through uni-professional focus groups alongside a selection of observations. Field notes were made at the time of the observations and a reflexive diary kept throughout. I transcribed the focus groups verbatim and uploaded them into NVIVO8 with analysis undertaken using template analysis (King, 2004). Whilst CP is now accepted as a fundamental part of contemporary health care (Barr et al., 2005; Dickinson & Sullivan, 2014) there is little clarity regarding either its meaning (Haddara & Lingard, 2013; Lingard et al., 2012) or of how it should be achieved (King et al., 2013) and could be the reason that measurements of its effectiveness are limited (Barr et al., 2005; Zwarenstein & Reeves, 2006). Exploration of CP within an emancipatory discourse ii however suggests a multitude of interplaying influences on how professions engage (Ansari et al. 2001; Haddara & Lingard, 2013). Indeed, findings from this study showed that whilst staff groups perceived CP to be positive, there remained a complex interplay of factors that impacted on how it occurred. In particular the dominant position of the doctor remained problematic influencing how, when and if it occurred. Physical space, elusiveness, communication methods, titles, language and tasks performed were all found to be significant in relation to the level and type of capital held and therefore the social space between professions. However, these were frequently masked by the physical space and distance between the staff groups. Bourdieu (1985; 1986) argues that the habitus of the individual is also influential in relation to social relationships as it is an inherent element of who a person is: influencing how they think as well as what they say and how they say it. The individuals’ habitus will ultimately manifest itself as a set of ‘tastes’ which shape their identity (Bourdieu, 1979) and how they engage with their environment (Bourdieu & Wacquant, 1992). The socialization of students into uni-professional practices resulted in their becoming indoctrinated into the epistemological norms of the profession to which they aspired: adopting similar tastes to their qualified counterparts. In this way the official criteria of WBL became lost in the unofficial criteria of social compliance to the hierarchical position held by their qualified counterparts (Billet, 2001a). The conclusions from this study argue that collaboration is complex and that greater recognition is required of those factors that impact on it: and in particular the power imbalance between doctors and nurses. Equally, current assumptions regarding students’ learning in this setting need also to recognize the complexities of CP, rather than simply relying on the experiences into which they are immersed to enable them to attain the goals of IPE and become ‘collaborative practice ready’ (WHO, 2010) at the point of qualification.

The desire for, and provision of, cross border reproductive services (CBRS) (i.e. gamete donation and surrogacy) is a growing international phenomenon. CBRS describes the travel by infertile patients from one country or jurisdiction where access to treatment is limited or unavailable to another country or jurisdiction to seek infertility treatment. There are numerous reasons for CBRS and it is an under- researched and undertheorised area of health research. The aim of this thesis was to explore patients’ motivations for and experiences of CBRS. This study provided themes on the decision making process of CBRS patients and contextualised them within a partial trans-Theoretical Model. Data regarding CBRS were collected from 26 international participants by means of asynchronous email in-depth semi-structured interviews via two international infertility networks. SPSS was used to analyse the quantitative data whereas NVivo 10 software aided the systematic thematic coding method within an Interpretative Grounded Theory. Participants’ motivations for and experiences of CBRS are complex. Seven stages of patients’ infertility journeys emerged: 1. Pre-contemplation: participants had no awareness of their own infertility; 2. Contemplation: participants became aware of their infertility and treatment at home and / or CBRS; 3. Preparation: participants researched CBRS using internet/infertility networks; 4. Action: participants took specific steps to initiate CBRS; 5: Maintenance: participants’ expectations and experiences were important to whether or not they would continue with CBRS; 6: Exit: some participants successfully built their family. Others’ overall experience was negative, their expectations were not met and they decided to quit treatment; 7: Re-engagement: some participants re-engaged with infertility treatment; some participants re-considered their decision regarding infertility treatment either at home or CBRS. A partial Trans-Theoretical Model could explain some of the decision-making process in seeking CBRS. Future research is needed to explore the implications of CBRS for patients, donors, offspring and healthcare systems.

The main aim of this study was to investigate student nurses' learning experiences. The study had two main aims: 1. To investigate the relationship between Learning Styles and Neuro-Linguistic Programming (NLP) representational systems in Pre-Registration Nurse Education. 2. To explore NLP representational systems as a means of enhancing teaching and learning in Preregistration Nurse Education Learning Style theory is well recognised in education, although there are some criticisms related to its validity and reliability. NLP is making a major impact on communications, learning and development in the commercial, health and sports sectors. Cognitive Psychology and the concepts of information processing and learning strategies encompass both learning style theory and NLP and is therefore utilised as a theoretical framework in this study. The study was conducted in two parts: Firstly, a questionnaire was delivered to student nurses to ascertain their learning style and internal representational preferences. From this a correlational approach was established to highlight important relationships. Secondly, some of the students were video interviewed to determine how they structured their learning experiences internally and how this was demonstrated in their body positions. The findings showed that Honey and Mumfords' Theorist learning style was most strongly preferred amongst this sample population. The Visual internal representational system was preferred over the Kinaesthetic and Auditory modalities. The Theorist learning style and Visual modality also showed a positive correlation, as did Activist and the Smell modality. It is recognised that learning style preferences should be used for students to gain awareness of ways to enhance their learning, and that rich, multi-sensory learning environments should also be encouraged. In. the light of the findings in this study it is suggested that the visual modality be utilised, via the use of visual tools and metaphor, and that approaches such as problem based learning (PBL) should be considered in order to benefit students of all learning style preferences.

Aim of the Study: Personal Tutoring is a scholastic mechanism to aid and support students while on a demanding academic and clinically orientated pre-registration nursing programme. Personal Tutoring is widely used in nurse education programmes, although it is often poorly structured with a minimal evidence base and rarely evaluated. The increased numbers of student nurses has seen the role of the Personal Tutor as an intrinsic factor towards a positive student experience. Attrition is an important consideration, but this study aimed to enhance the staff and student roles through tutoring. Methods: this study, influenced by ethnography, adopted an action research methodology as it encapsulated a constant problem-solving technique. This involved the exploration of academic staff and student perceptions of a Personal Tutor's role within a School of Nursing and Midwifery. Staff and students contributed to semi-structured interviews after a series of focus groups. The focus group discussions utilised the nominal group technique to rank the key points of the posed questions. These priorities were the basis of five staff and five student follow-up semi-structured interviews; the transcripts were manually analysed for trends and complemented with the use of the computer software NVivo 7. This resulted in the development and implementation of School Personal Tutoring Guidelines based on 'good practice', along with supporting evidence from published research. A follow up focus group and questionnaire evaluated the staff's and students' experience of the guidelines, along with a more detailed analysis of two case studies using appreciative inquiry. Findings: the staff and student focus groups both agreed on areas of good and poor practice in relation to Personal Tutoring; there was also clear agreement about what did and did not contribute towards a supportive Personal Tutor commitment. The Personal Tutoring guidelines were formulated around eight key and shared areas of responsibility, which was a shift from previous approaches. The guidelines were implemented for staff and students through formal mechanisms and the Personal Tutor relationship became a central instrument for existing and future curriculum development and teaching and learning strategies. The follow-up evaluation continued to illustrate variable commitment from both staff and students towards Personal Tutoring, although the majority of the data indicated a positive influence on staff and student experience. Conclusions: the established guidelines form a standardised Personal Tutoring system based on academic staff and student perceptions of the tutoring role. This has subsequently been disseminated to all areas of the faculty, therefore utilising the cyclical ethos of action learning. Kolb's (1984) experiential learning cycle is used to illustrate the originality of this work and demonstrates how it has added to the existing body of knowledge on Personal Tutoring.

The primary aim of this longitudinal study was to evaluate the effect of an educational programme upon the attitudes of nursing students toward working with ill older people, with two main objectives: 1. To explore the contextual conditions necessary for the programme mechanisms to work, and 2. To investigate how these contextual conditions may influence the success of the programme mechanisms in changing attitudes. Critical realism provided the theoretical framework, which guided the study design, from inception through to data analysis. Katz’ (1960) functional approach to attitude change was used to develop the educational programme. The study was quasi-experimental, using an interrupted time-series design. The attitudes of two groups of nursing students were measured over a period of 20 months, prior to and after the educational programme. A questionnaire-based tool was used to measure attitudes, selected because of its acknowledgement of the importance of contextual factors when measuring the attitudes of nursing students toward the field of older person care. One group attended the educational programme, the other did not. The attitudes of the second group were measured at identical points, to provide data for comparison. The findings showed that the programme had no effect on the attitudes of nursing students toward working with ill older people, either immediately, or over time. Both existing and new mechanisms were identified, that appear to adversely affect the context in which nursing students learn about the practise of nursing, and make it difficult for students to experience the care of ill older people in a positive way. Detailed analysis showed that elements related to the clinical learning environment have a strong impact on students’ attitudes towards the care of ill older people; very often, this impact is negative. The reality of clinical practice, it appears, is highly influential on students’ attitudes toward working with this group. The critical realist conception of a stratified clinical learning environment was developed in this study, informed by the work of Brown (2009). Mechanisms related to the structures and people in the clinical learning environment were identified which if addressed locally, may be pivotal in improving the contexts in which nursing students learn about the nursing care of ill older people. The original contribution that this study makes relates to how nurse educators can begin to improve the attitudes of nursing students toward the nursing care of ill older people, by improving the contexts in which they learn, with reference to their mechanisms. In line with this study’s findings, developmental work should begin within the psychological stratum, with concurrent action in both the socio-cultural and curricular strata of the clinical learning environment, in order to provide more immediate improvements in students’ placement experiences. A number of recommendations were made that would begin this developmental process, and may result in negating the need for attitude change programmes, with the ultimate intention of improving the quality of care for ill older people.

Introduction: There is a scarcity of research examining spirituality and spiritual dimensions of Advanced Nurse Practitioner practice. This thesis explores the findings of a hermeneutic enquiry into the spiritual dimensions of Advanced Nurse Practitioner consultations in Primary Care through the lens of Availability and Vulnerability. The findings include Advanced Nurse Practitioners’ understandings and conceptualisation of spirituality, the place of spirituality in practice and some of the concerns related to integration in practice. The participants’ interviews explored their own personal and professional experiences which added to their conceptualisation of spirituality. The lens of Availability and Vulnerability (A&V) was used intentionally and openly to explore, in depth, spiritual dimension of practice with the participants. The utility and effectiveness of the concepts of A&V in this context was explored. Methods/Methodology: A hermeneutic phenomenological enquiry was chosen to explore spirituality through the lived experiences of the Advanced Nurse Practitioners (ANPs). Eight participants were interviewed face to face during 2 in-depth interviews spaced 18 months apart. The concepts of A&V were introduced to the participants before the second interviews. The lens of A&V was utilised within these interviews to discover whether or not these concepts were helpful for operationalising spirituality in practice. The prolonged engagement allowed dialogue to occur between the researcher and participants allowing data to be captured which provided a thick description of the phenomenon of spirituality. A thematic analysis was chosen to interpret the data in order to enable a deeper understanding of the spiritual dimensions of ANP consultations to be gained. Findings The participants recognised that spirituality can be difficult to conceptualise and operationalise in practice. However, many of the participants were able to articulate the meaning of spirituality for themselves and gave examples of when they had witnessed a spiritual dimension occurring in practice. Particular themes were expressed in the interviews in relationship to spirituality. These included the context for spirituality to be integrated into care, the emotional engagement needed and the emotional impact on the ANP and the patient. Having introduced the concepts of A&V to the participants, after deep exploration, they recognised and identified that A&V were concepts which could be a useful lens for understanding spirituality in ANP consultations. Conclusion This study has uncovered new knowledge and understanding in the realm of spirituality in ANP consultations in Primary Care. The conceptual understanding of spirituality and the framework of Availability and Vulnerability provides a new approach to spirituality within ANP consultations in Primary Care.

This qualitative study takes an interpretative phenomenological approach to understand the experience of whiplash injury from the different perspectives of patient and doctor. This was carried out in order to identify what psycho-social consequences might be experienced by patients as a result of that injury and to identify any implications for healthcare provision. The research was conducted in two phases. During Phase One, eight patients were recruited through GP practices using a combined approach of retrospective and prospective sampling. Three semi-structured interviews and one telephone interview were carried out with each participant over a twelve month period. In keeping with phenomenological methodology, data were analysed using Template Analysis (King, 2004) and a set of themes relating to healthcare experience were identified: „embodiment‟ „experience of pain‟ „disruption to lifestyle‟, „making sense‟, „patient as expert‟ and „whiplash: a minor injury?‟. During Phase Two, one semi-structured interview was carried out with eight doctors who worked in either the primary or secondary care settings. Data were analysed using Template Analysis and a set of themes relating to their experiences of treating patients was identified: „expectations regarding what patients will experience‟, „what patients do about their whiplash injury‟, „what doctors do‟ and „blame if things go wrong‟. These findings show how the patient participants‟ physical and psychological experiences of their malfunctioning body had consequences for maintaining their sense of self and their ability to carry out their normal everyday activities at home and work. The doctors‟ own expectations of treating patients with whiplash injury and whether or not they trust the patients‟ account have illustrated three approaches: dismissive, reactive or proactive that have different implications for patients‟ experiences of healthcare. The study shows how the notion of „compensation‟ is implicated in whether or not the doctor feels able to trust the patient‟s account. The implications of these findings can be seen in terms of methodological focus, general practice and policy formulation. Methodologically interpretative phenomenology provides a theoretical foundation that is, at the very least, equal to and able to challenge more „traditional scientific foundations‟ through its focus on meaning. In terms of practice and policy formulation, the findings have provided a unique insight that might prove to be beneficial for understanding the health care experience and assist in the provision of guidelines aimed at the treatment of whiplash injury. Indeed it is advocated that doctors adopt a subjective approach and that this is taken into account in training.

This study has identified the knowledge, skills and attitudes required by qualified nurses who care for children in Accident and Emergency (A and E) following trauma. These requirements were then compared with the current attributes of such nurses. The researchm ethodologyw as carriedo ut in three phasesa fter an extensives urveyo f the relevant literature. The identification of the level of knowledge, skill and attitudes required for best practice was achieved by the first phase: a Delphi study, being a structured approach to collecting the opinions of a panel of qualifieda nd experiencedc hildren's nurses.T he actualk nowledge,s kills and attitudes that nurses have and apply in practice were identified by the second and third phases of the research.R egisteredn ursesc aring for children in three A and E units were surveyedb y questionnairew hilst further dataw as obtainedb y nine sessionso f participant observationi n three A and E units. Ile three sets of results have been compared and contrasted with each other and with the review of the literature and this triangulation approach has led to a number of key findings. The care needs of traurnatised children are different from those of adults; at present the majority of children are not cared for by nurses with the necessary competence or within an appropriate environment. Children need holistic care, not just the treatment of their medical injury. ibis study has uncovered a specific education and training challenge, because most of the registered nurses in this survey who do care for traumatiscd children think they arc competent in that specific and distinct role, although the observations showed that this is not always the case. Such nurses should be trained in both paediatric and A and E nursing skills. Tl-ýs can and should be achievedb y personaliseda nd flexible courses. The recommendationsa rising from the key outcomesh ave been made separatelyto educationa nd training providers, to the nurses themselves and finally to the health care policy makers and managers who control the clinical environment for the A and E nursing of children's care. 11c recommendations to the education and training providers arc specific to the content of the curricula for training nurses who care for children and to the structure of the corresponding courses. Adult-trained nurses, however expert in that context, are recommended to seek the advice of their child-traincd colleaguesw ho care for children. Managersa rc recommendedt o benchmark the physical environment, culture and practices of their A and E Units against those in the Children's hospital. Iley are also recommended to work with education and training providers to support three different models of continuous professional development; models which reflect the different backgrounds and initial levels of compctcncc of nurses who care for children. The researchers uggeststh at, if theser ecommendationsa re actedu pon, then nursesc aring for children wiH be better educated and in turn the practices of caring for traumatiscd chUdrcn in A and E wiU also improve, and wiU better meet the needs of both the children and their families.

Background: In modern neurological physiotherapy practice, a patient’s neuroplasticity is harnessed, teaching them to develop motor control at ‘impairment’ level. Consequently, the patient relearns ‘normal’ movement, which in turn enables them to gain more efficient function and independence that has significant impact on their ‘life’. However, there are no outcome measures that capture the patient’s quality of movement, or the specific effects of physiotherapy intervention. Such an outcome measure, the Leeds Movement Performance Index, was developed to fill this gap. It was hypothesised to be a valid, reliable and clinically useful tool. Methods: A multi-centre, three-part, mixed-methods study was undertaken with three groups of neurological physiotherapists (n=34) and patients with neurological diagnoses (n=42). A range of quantitative and qualitative methods were used: Consensus methods to develop the new outcome measure; psychometric tests to examine reliability and validity against existing outcome measures in the field; focus groups, face-to-face interviews and reflective writing to further explore clinical utility. Results: The Leeds Movement Performance Index was shown to be a tool with strong measurement properties i.e.: internal consistency (Chronbach’s, overall scale=0.862), inter-rater reliability (ICC=0.959); test-re-test reliability (rho=0.792); and criterion validity compared with the Berg Balance Scale (rho=0.468, SD±2). Thematic analysis demonstrated robust content validity and clinical utility. Furthermore, it un-expectedly revealed that the Leeds Movement Performance Index also supported fundamental aspects of neurological physiotherapy clinical practice, including assessment, analysis and clinical reasoning, and potential usefulness as an education aid. Conclusion: The Leeds Movement Performance Index makes an important and novel contribution to the field of neurological physiotherapy, both clinically and within research practice. It is the first outcome measure to conceptually map the nature and definition of quality of movement for patients with motor impairment, and it captures the impact of neurological physiotherapy intervention more responsively compared with other outcome measures routinely used within the field.