Background: In stroke services, providers are challenged to address the needs of people from ethnic minorities. Aim: This thesis will explore the stroke service needs of people from ethnic minorities, and how stroke services can address them. Part 1; Methods: Two group interviews with South Asian participants were used to inform an interview schedule. Using this schedule, 23 individual interviews were performed with South Asian participants, some of whom had experienced a stroke and some who had not. Part 1; Findings: Participants who had not used stroke services held positive expectations about those services. Participants who had used stroke services were negative about their overall experience. Attitudes and behaviour of service providers were seen as poor, and that they lacked an understanding of culturally specific issues. Participants expressed a need to be treated as an individual, to feel cared for and respected, and suggested that staff receive training to address this. Further research was needed to explore the efficacy of training service providers to be culturally competent. Part 2; Methods: Online databases were systematically searched for interventions evaluating service provider cultural competence training, and papers on theoretical frameworks of cultural competence. Components of theoretical frameworks were compared and evaluated. The training literature was evaluated and synthesised using realist methods. A stakeholder group reviewed the findings and made recommendations for practice. Part 2; Findings: Three overarching components reflected these theoretical frameworks, which were; cultural awareness, knowledge and skills. The success of training interventions, underpinned by these components, varied by the type of outcome measured. Where intervention outcomes were based on service providers’ self-reports they were perceived to be effective; where outcomes were based on service-user ratings they were perceived to be moderately effective, and where outcomes were based on clinical assessments they were perceived to be ineffective. The few studies with service-users rating their experiences indicated that a more detailed awareness of cultural issues coupled with practice improved ratings. Other studies have demonstrated that service-user ratings and outcomes can be improved by individuals, or teams, with effective levels of cultural skills implementing subject-specific health interventions. Underpinning these interventions were the understanding of service-users’ cultural needs, matched with appropriate skill-sets of teams or individuals. A stakeholder review of these findings confirmed that raising cultural awareness is an important first step in improving staff cultural competence. In addition, translating training into practice and matching the expectations of minority group stroke service-users, requires on-going support at an organisational and leadership level, with which confidence can develop through mentorship and shaping. Conclusion: The available evidence has shown how to provide cultural awareness knowledge and skills training, but not how to translate this into practical cultural competence. This thesis explores further exiting evidence to draw out components and mechanisms that seem to truly deliver cultural competence. Based on a systematic literature search and a realist review, this thesis proposes a model to suggest how true cultural competence can be achieved.

Nurses in Palestine work in a significantly challenging environment within and outside their workplaces. Mental health services in Palestine are underdeveloped and under-resourced. For example, the total number of community mental health nurses (CMHNs) in the West Bank is seventeen, clearly insufficient in a total population of approximately 3 million. This thesis is concerned with the resilience of nurses who work in community mental health workplaces in Palestine. This research explored sources of resilience and daily challenges that Palestinian CMHNs face within and outside their demanding workplaces. The up to date understanding of resilience is drawn from the social ecological perspective. Within Arabic culture, resilience has traditionally been conceptualised as a prerequisite to understanding and achieving ‘Sumud’, meaning that the individual has to be resilient in order to remain steadfast in the face of daily challenges and not to leave their place or position. An interpretive qualitative design was chosen to explore resilience and the daily challenges. Fifteen face-to-face interviews were completed with participants. Thirty-two hours of observations of the day-to-day working environment and workplace routines were conducted in two communities’ mental health centres. Written documents relating to practical job-related policies were also collected from various workplaces. Thematic analysis was used across all data sources resulting in four main themes, which describe the challenges faced by CMHNs and their sources of resilience. These themes consist of the context of unrest, societal challenges, lack of resources and organisational challenges. These sources are Sumud and Islamic cultures, supportive relationships, making use of the available resources, and personal capacity. The study concludes with a better understanding of resilience in nursing which draws on wider cultural contexts and responses. The outcome of this thesis will be used to develop the resilience of CMHNs in Palestine.

This thesis is concerned with the observable tensions within, and about, leadership of the nursing profession. Specifically the tensions between the leaders of nursing service and of nursing education is the focus of the investigation. Although both groups within the profession have a shared experience of socialisation; learning professional nursing values; professional control, and leaders careers regularly embrace both segments, never-the-less conflict between the two has been a consistent feature of the profession for most of this century. In order to explore these tensions qualitative data collected via in-depth interviews with 51 people who held leadership positions in nursing education between 1948 and 1995 are presented. This thesis analyses those factors which have contributed to the current situation. An exploration of the career pathways of those interviewed is undertaken and the influences of their individual attributes, knowledge, beliefs and values on the way in which they undertook their leadership roles are examined. Also explored are the ways in which other people were significant in affecting their careers and their approaches to professional life and work. In addition the environment in which they performed was a notable feature of consequence to them in developing the techniques of management used. From an analysis of these factors the ways in which they responded to and coped with changes in health care delivery in the period studied, through developing or adopting different leadership styles, is derived. This analysis suggests that in the period studied nurse managers used one of three main styles of leadership to achieve their goals. Some nurse leaders acquired positions of power in order to shape and develop nursing and nursing education; some pioneered innovations in nursing and nursing education, especially in the higher education environment; and others sought to motivate colleagues and peers through education, enabling and empowerment. The current tensions within nursing leadership are attributed to differences between their conceptions of nursing; their caring values; and the styles of leadership they developed in order to achieve their aspirations to provide the best possible quality of care for patients and of education for students. One of the chief sources of tension appears to be the juxtaposition of these two, sometimes competing, aims. Finally recommendations which refocus nursing as a caring occupation, whose practitioners act in partnership and cooperation, rather than autonomously and in competition with its various stakeholders, and the implications of this on the future recruitment, selection, education and preparation of nursing leaders are made.

Administering medicine to children is a part of everyday nursing practice that is complex and multifaceted. However, medicine errors are prevalent in all areas of nursing. One means for strengthening a system of safe medicine administration might lie in developing student nurse preparation for registered practice. This thesis evaluated nurse preparation for administering medicine to children using a multi-stage descriptive design. Preparation through one Diploma in Nursing was evaluated over a period of two years. 20 registered nurses were initially interviewed, and 201 activities characterising practice in administering medicine to children were identified. Activities were formulated into a questionnaire and were rated by 66 students and newly registered nurses according to their perceived involvement. In a second data collection, student perceptions of their involvement were compared with those of their practice-based assessors. Respondents viewed themselves as highly involved in activities requiring simple practice tasks and communication with families and children, while they were less involved in decision-making, teaching of peers and a small number of more advanced ‘adventuring’ activities. At qualification, although nurses had completed all theoretical and practical outcomes they still perceived themselves as not fully involved in 25% of practices relating to medicine administration. This supports existing work in relation to the transition of students to registered practice, but is unique in providing specific evidence related to medicine administration. Perceptions of the level of involvement varied between the practice based assessors and their students, but no significant difference was established between the responses of students who were assessed by assessors and those who were not. Student self-perception may not therefore be consistent with observed practice assessment, and should be explicated as an important part of progress evaluation. To determine whether course material corresponded to student learning, teaching materials were analysed and compared with student involvement in the role. In medicine administration process and in legal implications there was an increase in student perception of involvement that corresponded with the time they received teaching. They were less immediately involved in activities requiring mathematical skill and pharmacological knowledge, suggesting learning may need greater facilitation in these areas. In conclusion, nurse preparation should seek to address the breadth of role activities within the domains found in this work. Consideration of factors influencing effective role function and transition, as well as competence, should be included in a strategy for enhancing future practice.

The Productive Community Services (PCS) is a change programme which aims to engage frontline healthcare staff in improving quality and productivity. PCS draws on tested improvement methodologies such as Lean, however there has been little research specifically carried out on PCS in practice. The aims of this study were to explore the perceptions of the healthcare staff that implemented the programme, to identify the enabling and constraining contexts of the programme’s mechanisms of change, and to examine the meaningfulness and reliability of quantitative data generated during a PCS implementation. It also sought to explore the implications of these findings for managers, implementation teams, and commissioners in healthcare. To achieve this, an implementation of PCS was investigated using methods of participant observation, analysis of qualitative and quantitative data, semi-structured interviews and a focus group. A mixed methods approach was taken using the principles of Realist Evaluation. The results indicate that perspectives of the implementation varied widely, and that pay-for-performance targets contributed towards staff perceiving that the programme was irrelevant. Stock value was reduced by over £42,500, the time taken to find patient information was reduced by 62%, and services spent on average 36% of their time with patients. However, these figures lacked reliability and meaningfulness as the data were not validated or were produced using apparently flawed experimental designs. Contexts that constrained or enabled the mechanisms of change included staff attitudes, available resources, the effectiveness of communication, and whether technology could be used to resolve problems identified. The findings indicate that managers in healthcare should challenge implementation teams if the purpose of an innovation is unclear, that implementation teams need to be equipped with knowledge about technological solutions to efficiency in healthcare, and Commissioners need to ensure that pay-for-performance targets promote continuous quality improvement rather than temporary solutions.

Between 1993 and 2002, I have produced 32 publications representing a coherent body of work examining the development and implementation of nurse education policy in England between 1985 and 1997. A selection of 16 of these are included in this submission. Some of the others are cited mainly for the purpose of demonstrating the impact of my work. The work examines questions about the fundamental characteristics of the arrangements for nurse education, how and why these changed as they did over the period in question and the implications of these changes for stake-holders and participants. Answering these questions has required a wide-ranging multidisciplinary research programme theoretically informed by a number of disciplines including education, economics, policy studies and sociology, and including empirical work and archive-based primary source analysis. During the period in question, profound changes occurred in the arrangements for English nurse education. These are explained in policy terms, with reference to the intersection of two distinct but overlapping policy processes, firstly a professional project and secondly, the radical reform of the NHS under the Thatcher government. Examination of the implications of these issues is wide in scope, ranging from the position of individual nurses and nurse trainers, through college management, qualitative and quantitative workforce supply issues through to life-long learning barriers in the NHS. International comparative studies provide explanatory insights and the impact of the work is demonstrated through numerous citations among other forms of recognition.

It is acknowledged that caring interactions between younger, adolescent student nurses and young adolescent patients could precipitate particular difficulties and concerns for both parties during their journeys toward successful self-identity. The research undertaken identified two key dimensions: that of professional identity of the student nurses and that of illness identity for the young patients. These issues have been critically analysed using the theoretical underpinning of the seminal identity development theorists. In order to understand the true meaning behind the lived experience of both groups of participants during these caring interactions, a hermeneutic, Heideggerian, phenomenological study was undertaken. In line with this methodology individual, unstructured interviews were undertaken with 11 student nurses (aged between seventeen years five months to eighteen years eleven months) and nine young patients (aged between thirteen years and seven months and eighteen years and one month). Three main themes emerged from the data: (1) Messy boundaries; (2) Emotional security; (3) Being Younger making a difference. The findings highlight both concerns and benefits brought about by these caring situations. Concerns raised by the students relate to emotional distress, perceived lack of knowledge, confidence and professional identity. Also of concern is dealing with sensitive information disclosed by the young patients. Benefits identified by the students relate to being able to spend quality time with the young patients, being on the same level as them in informal ‘normative’ relationships, relieving their boredom and helping to momentarily distract them from their illness. Concerns highlighted by the young patients centre around issues of trust and confidence in the students’ professional abilities, the perceived lack of knowledge of the students in relation to their illness, and the students’ lack of understanding of their feelings. In common with the students, the young patients felt that the opportunities afforded them to ‘chill out’, be normal young people, and to be able to forget about the business of getting better, were invaluable. The friendships formed represent crucial therapeutic relationships which were not explicitly recognised by either party. The research has led to recommendations for improving student nurse education relating to young people/adolescents which it is anticipated will more appropriately meet the needs of the students and the patients. It has also enabled the creation of two models to support the unique engagement of the nurse-patient interaction, particularly in relation to the care of young people with a chronic illness: i) A Model for Processing Sensitive Information Revealed by Young Patients who may have a Chronic Illness ii) A Model of Adolescent Care Which Promotes Normalcy

This investigation aims to explore the area of change and knowledge translation in professional practice by using a case study to investigate the integration of a health policy into clinical mental health nursing (MHN) practice. It will address the research question of ‘What factors influenced the integration of Choosing Health (2006) and the Well-being Support Programme (WBSP) at the Trust’ by exploring how mental health nurses and managers of mental health services constructed and operationalised the recommendations of this policy into mental health services 2007-2008. A case study design and constructivist grounded theory methodology were used and the participants were taken from two groups who both worked in the Trust: registered mental health nurses (MHN) (n=28) and clinical managers of mental health services (n=18). Data were collected from the reflective accounts of the participants’ experiences of implementing the Choosing Health (2006) policy recommendations over a six month period during 2008. The Trust in this study was a large mental health and social care Trust in the South-East of England. Data were deductively analysed using a modified version of Lewin’s (1946) change theory which found six minor themes representing the factors that affected the implementation of Choosing Health (2006) in the Trust. The factors were common to both practitioners and managers and were: resources; policy and procedures; leadership in change; personal and professional development: support; motivation and innovation. The relationships between the six minor themes were examined further using inductive analysis producing three key themes that answered the research question of this study which are: organisational factors; professional factors and individual factors. This thesis argues that professional, as defined by Dopher (2012), influence in health policy both individually and strategically is weak, indicating deficits in professional influence, specifically in relation to organisational influence and professional representation. Further, shortfalls in professional influence at both local and national level were identified, resulting in under representation of the professional values, beliefs, codes of conduct and culture of mental health nursing (MHN). It is proposed that groups representing MHN should provide a higher profile advising on and developing mental health policy to improve the translation of policy into practice instead of its interpretation into practice. It also recommends that there should be an increased involvement in critically evaluating the professionally relevant evidence pertaining to the policy and an means of interpretation policy implications in terms of the practitioners related roles and responsibilities.

Whilst the Government has made explicit its stance towards identifying and taking into account the views of children and young people as service users it appears, within some hospital settings, that few openings are available to many children and young people, particularly those with learning or physical disabilities and acute illnesses. This qualitative study used an ethnographic approach to explore 46 children and young people's experiences of being in hospital. Data were collected within the hospital setting through unstructured participatory observation and semi-structured interviews alongside a variety of methods and activity based techniques. The data were collected and analysed concurrently in order to explore emerging themes in the analysis. The children and young people were diverse in terms of age ranges, experience of being in hospital and illness, with some being acutely ill and others having long term chronic illness. The findings revealed that children and young people experienced disruption due to being in hospital. This was experienced as a complex variety of factors, situations and people impacting upon their experiences. Interwoven within this disruption were feelings of powerlessness and uncertainty. Children and young people described experiencing disruption, uncertainty and powerlessness in terms of being in hospital, being ill and undergoing treatment and experiences of care and caring. In order to reduce these experiences children and young people undertook a range of strategies and actions in an attempt to restore equilibrium including "influencing", "accepting", "acting" and "positivity". Within this study I bring together for the first time the ways in which being in hospital creates disruption for children and young people and their agency and capacity in mediating their resultant experiences of powerlessness and uncertainty. I also provide an explanation for the ways in which children and young people experience disruption and restore equilibrium by drawing on Bronfenbrenner's work. The findings have implications for children's nursing in terms of quality and delivery of care for children and young people in hospital.

Little is known about people's responses to the impact of a transient ischaemic attack or minor stroke on their health status and future risk of stroke. In this thesis my aims are: to explore how the experience of TIA or minor stroke affects people's perception of their health and their uptake of health maintenance measures; to examine people's assessment, interpretation and perceptions of evidence in relation to their stroke risk; to explore the ways in which people reach decisions about treatment options in the light of their personal experience and in the context of evidence-based healthcare; and to explore the effect of anticipated regret in these processes. I conducted 28 audiotaped one-to one interviews with a purposive sample of 20 participants, each of whom had previously experienced a TIA or minor stroke. Ten of them had carotid endarterectomy in addition to best medical treatment (BMT). The data collection and analysis used a reflexive approach, based on my clinical nursing practice in this field, and was informed by the constant comparative method of grounded theory. My findings show that the experience of TIA diminishes people's quality of life and leads to a process of acknowledgement versus denial of its potential threat to health. People access evidence from formal and informal sources in the process of reaching decisions about their treatment. Their decisions tend to be deterministic in nature, even when they are aware of the scientific evidence. I present a theoretical framework, in which the central theme is the person's use of strategies to reduce uncertainty relating to their risk of stroke. I propose that people's primary aim in seeking health care, accessing information, and making treatment choices after TIA or minor stroke, is to reduce their perception of uncertainty about the threat of a future stroke, rather than to reduce stroke risk itself. I discuss the implications of these findings in relation to directions for future research, health care policy and nursing practice.