The nursing shortage in the Kingdom of Saudi Arabia (KSA) causes administrative difficulties and increases worries about the quality of healthcare being provided, as well as contributing to the employment of a multicultural nursing workforce. Evidence indicates that, although nurses are increasingly compliant with nursing policies and procedures to ensure a higher quality of nursing care, there is still a wide variance in that compliance. The Theory of Planned Behaviour (TPB) is a social cognitive model of behaviour used to investigate attitudes and behavioural relationships and to understand individuals’ behavioural intentions in relation to their performance. However, the TPB has not been previously used to attempt to explain this variance in a multicultural nursing workforce. The aim of this study was to examine the usefulness of the TPB in explaining variations in nurses’ intentions to comply with the pre-operative skin preparation policy. This study consisted of two phases, both conducted within a large military hospital in the KSA. The first phase, an elicitation study, was carried out to identify salient beliefs about compliance behaviour held by nurses working in general surgical areas. The findings from the elicitation study were used to develop the final theory-based questionnaire developed to understand the beliefs underpinning nurses’ intention to comply with the pre-operative skin preparation policy. The second phase of the study involved an anonymous and self-administered questionnaire designed to assess the variables in the TPB. The instrument included measures of behavioural intention to comply with pre-operative skin preparation policy, attitudes, subjective norms and Perceived Behavioural Control (PBC). Due to data that were not normally distributed, behavioural intention was dichotomised into high behavioural intention and low behavioural intention. A logistic regression analysis was used to test the relationships between the behavioural intention and the TPB variables. The results revealed that the TPB model explained up to 40% of variance in behavioural intention to comply with the pre-operative skin preparation policy, X2 (5, N=229)= 21.5, P<0.05. Results showed that attitudes (Odds Ratio= 3.86, 95% Confidence Interval= 2.07-7.20, P<0.05) and subjective norms were the significant predictors of nurses' high behavioural intentions. However, PBC (Odds ratio 1.30, 95% CI= 0.81-2.09, P>0.05) was not. In conclusion, the findings of this study support the usefulness of the TPB model in predicting nurses’ intentions to comply with a pre-operative skin preparation policy. The results could be used to develop effective intervention strategies based on the nurses' beliefs that underpin their behavioural intention to comply with hospital guidelines and policies. However, future research can confirm the result of this study and expanding the list of contextual variables.

This research was about the lived experience of caring for someone with dementia. Six informal carers of people with dementia were interviewed. The carers were defined as ‘informal’ as they were family and friends, and therefore unpaid. Five of the carers were women who had or were supporting their mothers, and one was a man, who had cared for a friend. Three carers identified as lesbian or gay. I wanted to hear the stories of a group that are generally neglected in research (Turnball, 2002). Carers are diverse with a range of needs, and I wished to discover if services were ‘gay friendly’ or implicitly heterosexist. In addition I wanted lesbian and gay carers’ stories to be heard and their contribution to be recognised. The research is important as there are an estimated 750,000 people living with dementia in the UK and 500,000 partners, family members and friends are involved in caring for someone with dementia at a value of £6 billion a year, if care was provided by health and social care services (Department of Health, 2009). The research method was biographical in relation to the participants’ caring role. It explored three areas: the experience of caring, coping approaches and encounters with health and social care services. The interviews with carers took place in 2010 and the cared for had, or were living in: London, Wales, south-east and north-west England. The theoretical perspective of the research was person centred (Kitwood, 1997) set within the legislative and social policy framework for carers. The data was analysed primarily through pre-determined codes arising from the interview schedule and Skills for Care ‘Core Principles for Carers’ (2010) but also searching for patterns within and across cases. The findings were that the carers did not experience the person with dementia as a burden, but contact with health and social services was often problematic due to the fragmentation of services, lack of one practitioner co-ordinating care, and an absence of knowledge about carers’ legal entitlements. In addition services adopted a medical model of care focusing on the dementia of the cared for with limited interest in the cared for or carer’s biography, consequently services were not person centred, or gay friendly. Carers’ commitment to the person with dementia was on a continuum between the obligations of kinship and unconditional love. Positive aspects in the relationships endured in particular humour and shared activities. The messages for practice were that health and social care practitioners require training in person centred practice, as well as the legislation and policy framework for carers. Personalisation of services provides opportunities for shifting services from a task centred to person centred approach, including the development of gay friendly services  .

This study was carried out in the context of increased pressure on acute medical beds, increasing demand for alternatives to acute medical care and the need to reduce junior doctors' working hours. Nurse-led in-patient care has been advocated as a response to these pressures that also has the potential to improve patient outcomes. However, evidence to support the safety and effectiveness of this model of care was limited and came from Nursing Development Units, making it difficult to predict how well the model of care would perform in routine NHS practice. The nurse-led in-patient service was compared with standard care on the acute wards via a randomised controlled trial. Recruitment for the trial took 17.5 months. Key outcomes were length of stay following randomisation, discharge destination and change in physical functioning. Secondary outcomes were mortality, re-admissions within thirty days of discharge, falls, complications of hospitalisation. The process of care was explored by comparing medical reviews, therapy reviews, changes to medication and numbers of tests and investigations during the trial period. The nurse-led service did not demonstrate any improvement in outcomes, but substantially increased the length of stay in the treatment arm of the trial. The apparently higher rate of therapy reviews and rates of some complications were diminished when these outcomes were controlled for length of stay. Daily rates of medical reviews, medical investigations and changes to medications were lower for the treatment arm of the trial. The findings of this study do not support the limited benefit reported in previous studies. The widespread introduction of this model of care cannot, therefore, be advocated on the basis of improved outcomes for post-acute patients. However, the nurse-led intervention was not shown to be worse than standard care and may result in organisational benefits, such as reduced medical input. From the poor outcomes observed in this study, it would appear that neither nurse-led nor standard care is meeting the needs of this patient group. Further research is needed to identify and evaluate appropriate nursing interventions for post-acute medical patients.

Background: This study is set in the Indian State of Madhya Pradesh (MP) where maternal health is poor and women’s social status is low. In the majority of cases women’s autonomy and decision making within the family is limited and their ability to seek medical treatment is through their husband or father-in-law. The State government identified a need to strengthen midwifery care given by Auxiliary Nurse/Midwives (ANMs) in the hope of improving maternal and neonatal health. This study formed part of one Non-Governmental Organisation’s response to this need. Design: This cross-cultural, two phase study was designed in partnership with an Indian Non-Government Organisation, utilising Elliot’s Action Research model within the paradigm of critical theory. The first phase investigated the then current situation and established a potential solution to strengthening midwifery practice within MP. This solution comprised an educational approach using a specifically designed self-directed distance learning programme (DLP) focussing on normal pregnancy and childbirth. The DLP consisted of a hard copy workbook supported by a multimedia resource. The second phase was the use and evaluation of the DLP with a sample of 28 ANMs in MP. Their knowledge was tested using a pre- and post-test multiple-choice question paper. Data were analysed using Wilcoxon signed rank. Participants then negotiated a three day workshop to cover aspects they had not been able to address. A further 19 participants joined these three days. Outcomes: The MCQ test results indicated that the first group had poor knowledge of the normal process of pregnancy and childbirth. This group did not improve their personal performance scores significantly after the three day workshop. However, the second group demonstrated a significant change which suggests that coupling self-directed guided study material with an enabling, face-to-face environment can be successful. Conclusion: Distance learning may be more effective if coupled with face-to-face workshops. Partnership working was a crucial component of this cross cultural Action Research study which required attention to detail in all stages for a successful conclusion. Both of these points have relevance for others undertaking similar studies. Recommendations: Improved interface between global organisations and the Indian Government to improve midwifery education and status.

The study was in two parts. In Part 1 the thematic content analysis of the nurses’ individual accounts of their trial experience revealed how the CMHNs’ aimed to be an agent of change in the nurse-patient encounters and how the trial setting contrasted with everyday practice. Following this, detailed micro-analysis of the narratives of nurse-patient encounters found that the nurses’ goal to be an agent of change was not always borne out when the construction of their accounts was examined. In Part 2 the thematic content analysis of group discussions about CMHN role illuminated the tensions in CMHNs’ everyday practice and their perceived role with people with CMHPs outside of the experimental setting. Overall, the treatment of people with CMHPs was exceptional in that the nurses interpreted their trial experience in the way it contrasted with their everyday practice. Further, in line with the results of the randomised controlled trial, CMHNs did not think that people with CMHPs should be treated by specialist nurses within community mental health services. The nurses suggested a range of methods in which individual, community and primary care resources could be augmented to support people with the aim of preventing referral to specialist services. The integration of the key findings from both parts of the study demonstrated how the nurses used and valued a range of types and sources of knowledge, both in their practice and when forming their views about CMHPs and service organisation. These knowledge sources were not those valued in contemporary healthcare. The dominant evidence-based practice movement champions research evidence of effectiveness above other forms of knowledge. Broadening the understanding of evidence and narrowing the claims of evidence-based practice is suggested to permit all forms of knowledge to be valued in healthcare decision-making

Shoulder pain is associated with abnormal movement of the scapula. Quantitative measurement and classification of abnormal scapular kinematics, however, is difficult due to the gliding nature of the scapula beneath the skin surface, and large variation in data. The aims of this study were to determine the validity and reliability of the acromion marker cluster (AMC) in measuring scapular kinematics during the arm lowering phase, to measure poor control of the scapula in people with a history of shoulder pain and a group with shoulder impingement, and objectively classify poor control scapular control. The validity and reliability of the AMC was compared to the scapular locator. The AMC was valid during sagittal and scapular plane arm lowering movements (max root mean square error = 6.1°), but had poor to fair reliability (ICC = 0.12 – 0.76). The AMC was used to determine whether a group of people with a history of pain, and those with shoulder impingement, exhibited poor scapular control when performing a scapular repositioning clinical manoeuvre, compared to a healthy control group. The history of pain group exhibited an increased position of scapular downward rotation (-7.9° ± 6.3) at the end of the manoeuvre when compared to the healthy control group (0.3° ± 4.4). There were no statistical differences in people with shoulder impingement. A statistical classification technique based on the Dempster-Shafer Theory of Evidence (DST) was used to objectively classify participants as having poor scapular control. Six kinematic variables were was used as input in to the DST classifier which classified 5 out of the 6 history of pain participants as having poor scapular control, with an accuracy of 72%. The DST multivariate classifier was reasonably successful at classifying participants with poor scapular control suggesting its potential use for future analysis of abnormal scapular kinematics.

This qualitative study sought to examine perioperative nursing from the perspective of its practitioners. It was undertaken in two operating theatre sites within NHS Trusts in England. The study used the ethnographic approaches of non-participant observation and semi-structured interviews, with ten observation sessions totalling 85 hours undertaken and eight interviews conducted. Thematic data analysis was undertaken supported by the NVivo qualitative data analysis software program. Two main themes emerged as being core components of perioperative nursing work. The first, ‘Managing Momentum’, related to the work that the nurses undertook to ensure that the operating lists went smoothly and progressed throughout the day. The second, ‘Accounting for Safety’, focussed on the need to ensure that patients were kept safe from harm at all points of their perioperative journey. Three different perioperative nursing roles were identified (anaesthetic, scrub and recovery nurses) and these different types of perioperative nurse undertook managing momentum and accounting for safety work, but each enacted them differently. There was tension between the two components of the work that these nurses had to resolve. The study concludes that perioperative nursing is not a homogenous entity. Nonetheless, perioperative nursing centres on balancing momentum and risk. This insight provides a new understanding of this ‘hidden’ or backstage type of nursing practice. This work will inform perioperative nurses’ understandings of their work, and can also feed into formal definitions of perioperative nursing, recruitment and professional development.

Recent changes in nurse education in the UK (UKCC 1986) have emphasised particular values in nursing, such as individualised, holistic and research and evidence based care. However, the extent to which these values and ideals have been adopted by students and qualified nurses has not been explored, nor the extent to which they can be implemented in practice. This study is a longitudinal, naturalistic enquiry into the fate of the ideals and values of newly qualified nurses. At the end of their course students in three colleges of nursing were asked, via questionnaires (n=86), to describe their ideals for practice. Questionnaires and in-depth interviews (at 4-6 months and 11-15 months post qualification) were the methods used with a purposive sub sample of twenty-six participants, who were followed from the end of their Dip HE Adult nursing courses to up to three years post qualification (second questionnaire after 3 years). Interviews were tape-recorded, transcribed, and data were analysed using constant comparison and negative case analysis. The study found that the diplomates emerged from their courses with a cogent set of high ideals. The fate of these ideals in practice was dominated by two key forces: professional and organisational sabotage. Three groups emerged in the findings: sustained, compromised and crushed idealists. The key to the retention or otherwise of their ideals and values was the practice environment, together with diplomates' own strategies for maintaining ideals and motivation. Particularly important in the practice environment were support, role models and staff attitudes, and the adequacy of resources, especially staffing and skill mix issues. It is suggested that educational, policy and social changes have sharpened the professional-bureaucratic conflict in nursing, and that individual nurses are often caught in the middle of this conflict, with deleterious consequences for both individuals and for the nursing profession.

Background: Indwelling urinary catheters (IUCs) placed for short-term use in hospital frequently become long-term catheters, increasing the potential for infections, trauma and other complications. Current research has focused on the prompt removal of IUCs in place, with no published review of interventions to reduce the initial placement. Furthermore, little is known about why clinicians place IUCs in acute medical care. Without this knowledge, the effectiveness of strategies aimed at reducing IUC use is likely to be sub-optimal. Aim: To understand why clinicians decide to place IUCs in acute medical care. Methods: (1) A systematic review of interventions to minimise the initial placement of urinary catheters in acute care. (2) A qualitative study in the A&E department and acute medical wards of a 1200+ bed hospital. Clinicians who made the decision to place an IUC were asked to participate in a retrospective think aloud interview describing how they came to the decision, later participating in a semi-structured interview to discuss their wider experiences of making the decision to place an IUC. A purposive sample and thematic analysis were used. Results: (1) Eight (six uncontrolled) studies met the inclusion criteria for the systematic review, using a variety of interventions including clinician education and introduction of guidelines to reduce IUC use. Although seven demonstrated a reduction in the initial use of IUCs post-intervention (relative risk 0.19 – 0.86), the impact of individual interventions was unclear. Notably, each study provided a list of reasons considered to provide justifications for IUC use, with substantial variation between the lists. (2) 30 retrospective think aloud interviews and 20 semi-structured interviews were undertaken. Clinicians were influenced by cues taken from three groups; individual beliefs (e.g. on the clinical indication or IUC-associated risks), patient factors (e.g. age or gender) and organisational factors (e.g. resources or policy). Many spectrums of belief were found (e.g. varying opinions on using IUCs to protect skin from urinary incontinence). Conclusions: This work establishes that understanding of interventions to reduce the initial placement of IUCs is poor and there is a lack of agreement on when the benefits of IUC use outweigh the risks. Clinical reasoning in this area is frequently inconsistent and IUC placement decisions vary widely, indicating that there is considerable scope for a reduction in use.

This work was designed to explore the effect of cetirizine on mediator release secondary to intradermal bradykinin challenge in normal human skin. On intradermal injection, bradykinin produces a dose-dependant weal and flare response similar visually to that produced by histamine, suggesting that histamine release is involved in mediating the cutaneous response. This is further supported by the fact that premedication with cetirizine significantly inhibits both the bradykinin and histamine weal and flare. However microdialysis demonstrated that there is insignificant histamine release following bradykinin, and SLDI showed that the weal and flares produced by both histamine and bradykinin are different in nature, suggesting that other mediators, such as prostanoids or NO are involved. Although both prostanoid synthesis and NO release were observed following bradykinin, cetirizine failed to have any effect on the levels measured, suggesting that these are not the major mediators responsible for the bradykinin response. Cetirizine was shown to be able to inhibit the cutaneous responses induced by a number of agonists, namely bradykinin, histamine, and methacholine. All of these act via a specific GPCR, and each one having an alpha subunit of the Gq/11 variety. Therefore it is postulated that the bradykinin-induced weal and flare is mediated by activation of B2-kinin receptors located on sensory neurones, resulting in the release of neuropeptides, and that inhibition of this response is achieved by a direct inhibition of Gq/11 G-proteins, their regulatory proteins or modulation of a common second messenger system.