This study explores the subjective wellbeing and subjective experience of mental health problems in UK mental health nurses using a mixed methods approach. It aimed to understand the relationships between mental health nurses' own mental health and their subjective wellbeing, and to explore the ways in which mental health nurses managed their own mental health and wellbeing and how they negotiated for and use their experiences both within and outside of their work. The mixed methods design had two phases. In phase one an online survey was sent to mental health nurses via their national professional bodies, the Royal College of Nursing and the Mental Health Nurses Association. The survey comprised three measures of subjective wellbeing, questions about personal and familial mental health history and questions about the impact of these experiences on mental health nursing work. 237 survey responses were included in the final statistical analysis. In the second phase 27 semi structured interviews were undertaken with a purposive sample of survey respondents who had both subjective experience of mental health problems and high subjective wellbeing. A major finding of the study was that mental health nurses critically appraised their experience of delivering and receiving mental health care from the expert perspectives of both being a nurse and having their own experience of mental ill health. Personal experience of mental illness was found to influence nursing practice in a number of ways: first, through overt disclosure and negotiation of professional boundaries; second, through the ‘use of the self as a tool’, the emotional labour of nursing; third, through the formation and development of professional nursing identity. This was in the context of a broader canvas of life experiences which participants considered to influence the development of their nursing identity, the use of self and self disclosure in their work. Mental health nurses in this study had a relatively low subjective wellbeing. Low subjective wellbeing was associated with having current mental health problems, and with having past experience of mental health problem. Personal experience of living with someone with mental health problems was associated with relatively higher subjective wellbeing. This study has implications for occupational health and human resources policy within healthcare organisations. The findings suggest that mental health nurses who present to primary care or occupational health services should be offered care and treatment commensurate with their expertise and experience. Employers’ ‘staff happiness strategies’ and occupational health promotion activities should address work life balance and what nurses could do outside of their work to be well, as well as addressing the effects that team and management changes have on staff wellbeing.

Empirically, this thesis has focused on nine research and development (R&D) networks set up to promote a professional approach to care and strengthen the collaboration between health care sectors in a Swedish health care setting. The research project was embedded in an action research approach intended to encourage network development by means of a dialogical process. The specific research question was: What are the actors' perceptions of knowledge networks and how might we account for the networks' evolution, role and ways of working? Bourdieu's concepts reproduction and symbolic violence were used as analytical tools and were chosen as a way of answering and explaining the empirical story line. Data was collected by use of a multi-method approach consisting of 39 interviews, observations, document review and reflexive notes. The intention was to elicit data that supported both network development and the theoretical explanation to come. It appeared that the networks concerned had several advantages, such as being a forum for internal dialogue and exchange of experiences. In addition, two main patterns emerged: Firstly, most of the participants within the networks were advocates of a linear top-down model of implementation of evidence-based knowledge into practice. Secondly, they experienced inertia in the transfer process. From the collaborative process undertaken it emerged that their linear top-down model of knowledge transfer seemed to be firmly rooted. Theoretically, the thesis contributes to an understanding of why the process of knowledge transfer was considered by the participants within the networks to be a sluggish process. The thesis also contributes to an explanation of why they adhered to the macro-discourse of evidence-based medicine at the expense of involving practitioners outside the networks in horizontal patterns of exchange. It is argued that the networks had a symbolic value and were also a product of and reproduced the evidence-based discourse and the prevailing structures within their field. This contrasted with the role of networks as arenas for generation of local knowledge in the network literature. A major challenge facing health care sectors is that of how to support practitioners in the incorporation of new practices resulting in actual changes.

Background: The evidence base on end-of-life care in acute stroke is limited, particularly with regard to recognising dying and related decision-making. There is also limited evidence to support the use of end-of-life care pathways (standardised care plans) for patients who are dying after stroke. Aim: This study aimed to explore the clinical decision-making involved in placing patients on an end-of-life care pathway, evaluate predictors of care pathway use, and investigate the role of families in decision-making. The study also aimed to examine experiences of end-of-life care pathway use for stroke patients, their relatives and the multi-disciplinary health care team. Methods: A mixed methods design was adopted. Data were collected in four Scottish acute stroke units. Case-notes were identified prospectively from 100 consecutive stroke deaths and reviewed. Multivariate analysis was performed on case-note data. Semi-structured interviews were conducted with 17 relatives of stroke decedents and 23 healthcare professionals, using a modified grounded theory approach to collect and analyse data. The VOICES survey tool was also administered to the bereaved relatives and data were analysed using descriptive statistics and thematic analysis of free-text responses. Results: Relatives often played an important role in influencing aspects of end-of-life care, including decisions to use an end-of-life care pathway. Some relatives experienced enduring distress with their perceived responsibility for care decisions. Relatives felt unprepared for and were distressed by prolonged dying processes, which were often associated with severe dysphagia. Pro-active information-giving by staff was reported as supportive by relatives. Healthcare professionals generally avoided discussing place of care with families. Decisions to use an end-of-life care pathway were not predicted by patients’ demographic characteristics; decisions were generally made in consultation with families and the extended health care team, and were made within regular working hours. Conclusion: Distressing stroke-related issues were more prominent in participants’ accounts than concerns with the end-of-life care pathway used. Relatives sometimes perceived themselves as responsible for important clinical decisions. Witnessing prolonged dying processes was difficult for healthcare professionals and families, particularly in relation to the management of persistent major swallowing difficulties.

As the demands on the NHS increase, nurses are facing the challenge of attempting to implement innovative and new roles in clinical practice. Changes such as the reduction in junior doctor hours, evidence based practice, and recognition of nursing's contribution to health care delivery, have acted as catalysts for professional development. At the same time, the UKCC's ongoing quest to have nursing establish itself as a major professional discipline has resulted in the recognition of different levels of nursing practice. The highest and most complex level is that of the "advanced nurse practitioner" (ANP), who is expected to be prepared at the Master's degree level. This study set out to explore the transitional process of nurses undergoing the academic and clinical preparation to become ANPs. A qualitative design, utilising five case studies, was used as the main research strategy. In addition to the ANP, each case comprised a number of medical, managerial, educational, and nursing staff. Data was collected by individual interviews, observations and documentary analysis. Supplementary data was collected through the completion of role development diaries by an additional 8 ANPs. Data collection was completed over a two year period and analysed with the assistance of the NUD-IST computer program. It was found that the transitional process of becoming an ANP involved the reconstruction of nursing in seven personal and practice domains. Both the transitional process and outcome were contingent upon the influence of key stakeholders within each institution. Consequently, role transition resulted in one of three operational outcomes: practice replication; practice fragmentation; or practice innovation. Regardless of outcome however, all ANPs sought to establish a new and unique identity as a way of escaping the organizational and occupational constraints placed upon them, and to gain recognition and professional empowerment.

There has been much written regarding nurse education and the socialisation of student nurses in clinical areas in the past (Olesen & Whittaker 1968, Orton, 1981, Melia, 1987, 1997, Ogier, 1989, Castledine, 1995, Bradshaw 2001, Spouse, 2003). The originality of this thesis lies in the discussions and exploration of the concept of Problem Based Learning (PBL) as a teaching and learning strategy and the implementation of the Making a Difference (DoH, 1999a) recommendations in a nursing curriculum. It investigates whether or not these have indeed made a difference to the ability of the students to socialise into their clinical roles and effectively meet their ultimate aim of becoming a ‘real nurse’. The thesis is split into five chapters and employs qualitative research methods to present an ethnographic case study of the experiences of student nurses in clinical placement areas regarding the process of becoming effective student nurses who ultimately develop their knowledge and skills base to become ‘real nurses’. The sample consisted of fifteen (15) students, fifteen (15) student mentors, eight (8) ward managers, one (1) practice development coordinator and one (1) senior nurse responsible for clinical development. Interviewing and observation techniques were used to obtain the data. PBL as a teaching and learning strategy is investigated and discussed, in relation to the students’ ability to develop critical problem solving skills that can be incorporated into their student roles. The disadvantages of PBL are also debated and issues highlighted that may cast doubt that this strategy and the Making a Difference curriculum has actually changed attitudes in the clinical areas towards the capabilities of the student nurse role. Eight major themes arose from the data analysis; learning to be a student, fitting into the clinical team, being professional, being a real nurse, the role of the practice development co-ordinator, effective mentors, developing clinical skills and reflecting in practice. Integral to these were the concepts of professionalism, power, inequalities and culture that were identified as significant underlying issues for the students to recognize when performing and developing into their clinical roles. The data suggest that the new curriculum and PBL have offered some solutions to help overcome the perceived boundaries of professionalism, power, inequalities and culture but by no means provides all the answers. Overall the study has highlighted the importance of clinical skills development and effective delivery of them by students in learning to become a ‘real nurse’. Through their experiences the students have learnt how to overcome boundaries and to fit in with the culture of clinical areas thereby enabling them to learn the role of the student nurse. Furthermore, the newly developed roles of the practice development co-ordinator and established mentor roles are perceived to be invaluable sources of support for the students while in clinical placement areas.

Aim: To focus on an exploration of the NC role and its engagement with and influence on the research agenda for nursing, Background NC posts have only been established in the United Kingdom since 1999. The role is intended to incorporate four domains: expert practice, leadership and consultancy, education and training, service development and research. Although there has been professional literature regarding the role development in general, there is little written regarding the development of the research aspect and how this influences the research agenda for nursing. Design A qualitative exploration of the research component of the NC role was undertaken using semi-structured audio-recorded telephone interviews with 13 NCs across England. Data were analysed using McCormack’s (2000a) multiple lens approach, a framework that facilitated thematic analysis. The study was informed by the theoretical frameworks of Professional Socialisation and Benner’s (1984) Stages of Clinical Competence, which allowed critical analysis of the data. Findings In relation to the development of the research component of the NC role, the data suggest that NCs were poorly supported in clinical practice, and that, although most held Masters Degrees, this educational level did not provide NCs with adequate preparation for the role or for delivery of the research component of their role. There was also poor understanding of the research role by the authors of NC job descriptions who comprised of NCs themselves, service managers or Directors of Nursing. Research has both an academic and clinical focus in relation to development, infrastructure support and delivery and therefore I expected that Higher Education Institutes (HEIs) would have been involved in the development of the research aspect of the NC role. However, there was very little or no engagement with HEIs by authors of the job descriptions in most cases. Constraints of the clinical environment around service pressures, competing demands, coupled with a lack of mentorship and the absence of a research culture and inadequate links with HEIs were other factors contributing to the barriers to research development. However, the findings revealed that NCs contribute to the research culture within their organisations through various levels of engagement, but there was little in the way of active involvement in research projects. Implications for Practice/Research This research has added to the body of knowledge concerning how, in clinical practice, NCs are socialised into the world of research and what support should be available to ensure NCs deliver on the research aspect of the role. Research and Development activities are considered a major job requirement, where there is an expectation that research will be conducted in a specialist area. This study has concluded that NCs are a group of expert nurses who are visibly making a difference to EBP but not necessarily in the way first envisaged when the roles were developed. This study has highlighted an emerging conceptual framework CFRE (Allen et al. 2004) which could be used to operationalise the research component of the role. The emerging field of implementation science is recommended for the development of the research element of the NC role in order to accelerate the EBP agenda for nursing. Key stakeholders who currently employ NCs should review the infrastructure and support provided to deliver on this.

This is a qualitative case study of socio-technical work. This study provided a rare example of an in-depth study of an electronic patient record system in (recent) use, in the only site in Wales where this was possible. The study explored the actual use of the Welsh Individual Health Record (IHR) technology by the multi-disciplinary team members working in an emergency medical assessment unit (EMAU). Purposeful sampling was used. Data collection methods were interviews, informal observations and documents. Interviews were audio recorded and transcribed verbatim. Complex Adaptive Systems Theory was used as the lens during data analysis. Three main themes emerged: Managing the dynamic context of the EMAU; Patient safety and Issues with the adoption of the IHR. Clear findings emerged on the usefulness of electronic patient record re: medication safety, bridging the intersection of care, as a vessel for information in the case of patients unable to give their medical histories and facilitating co-production to enhance safe, patient-centred care. The IHR system can mediate the information gaps and should not be developed as static entities but should be allowed to grow and adapt to emergent user requirements.

The aim of this thesis is to explore the experiences of siblings within their family, who are living with a child with a life limiting chronic illness. Siblings have been identified as being a marginalized group because there is limited recognition of their sibling voice within the literature and in family centered care practices. Family centred care is an important aspect of children’s nursing in terms of inclusivity and maintaining dignity and respect of the whole family and needs to include the sibling. Therefore specific insight into their worlds is presented to inform care because siblings do need help when journeying along the cystic fibrosis trajectory with a brother/sister. A qualitative methodological narrative inquiry has been elicited to engage siblings within the context of their family with the use of a bricolage of creative participatory methods (n=10 children in middle childhood living with a brother/sister with cystic fibrosis). Narrative interviews, observations and the use of visual media have provided the platform for the siblings expression of their performed voice that was encapsulated in the collection of over 200,000 words of data, along with pictures, poems, songs and artifacts. Goffman’s theoretical framework of dramaturgy was used as the exploratory ‘lens’ in which to view the sibling’s front stage, back stage and centre stage stances. Microsoft word was used to conduct a thematic analysis of the data collected (observations, interviews and visual media), which provided an insight into sibling position, space, roles encompassed in their overall self-presentation in their familial/cultural milieu. Data analysis is presented as a three-act play called “The segments of the sibling mosaic” where the siblings are performing on the stage set of family life within their home. Through interactive performances siblings act out scenes of multiple presentations of self to reveal the contradiction between their ideology and reality of their lives as a consequence of the opposing force of cystic fibrosis. Through the use of Goffman’s framework I suggest that the children’s expression of voice goes beyond the use of the spoken word, as siblings gave voice through their constructed and co-constructed performances. I also suggest that siblings are skilful in their interactions as they are able to fluctuate easily between their dramaturgic front stage and back stage stances. I argue that siblings are placed in a decentralized position in family life and I introduce three prominent positions/spaces where these children stage themselves, which are “in the wings”, “left of centre” and in the “off stage place sets”. I highlight how siblings demonstrate diplomacy and wisdom in their communicative interactions of being good so as to remain protective, loyal and maintain family equilibrium. I argue that siblings should not be labeled or referred to as being well or healthy in the absence of physiological illness, because they provide an insight into their emotional self where a need for help is identified. Bringing siblings to centre stage and using creativity in this study has identified one way of helping them to share their experiences and enabling their voice to be heard to inform future aspects of care. However, further research is suggested.

Spirometry (lung function assessment) is an essential tool for the chronic disease management of chronic obstructive pulmonary disease (COPD). Chronic disease monitoring for COPD was introduced in 2004 and included spirometry for target achievement and financial remuneration within the Quality and Outcomes Framework of the General Medical Services Contract. However, practice nurses have anecdotally struggled to gain competence and expertise with the spirometric procedure and interpretation post 2004, despite the successful achievement of financial targets within the general practice setting. A sequential exploratory mixed methods study (Tashakkori and Teddlie, 2003) was undertaken within a University Health Board in Wales to determine what, if any, barriers exist for practice nurses undertaking spirometry assessment and interpretation for the chronic disease management of COPD. Quantitative data were collected via an online questionnaire. Qualitative interviews were conducted and analysed using an analysis framework method (Ritchie et al, 2003). The methodological framework of the feminist transformative lens (Caracelli and Greene, 1997) was utilised to gain an understanding of the barriers practice nurses faced in the gaining of competence with spirometry assessment and interpretation within the wider professional context. The quantitative results confirmed the anecdotal reports of difficulty with spirometry and demonstrated that lack of training was the greatest reason for lack of confidence in spirometric interpretation, followed by lack of clinical time and lack of general practitioner (GP) support. The qualitative results demonstrated that practice nurses are commonly working as disenfranchised isolated practitioners within general practice teams, and are commonly undertaking a procedure in which they are not highly confident. Recommendations for development of future clinical practice are: mandatory training with assessment of competency to improve skills with spirometry, in addition to supervisory support and training of GP colleagues. Other recommendations include: a greater focus on inter-professional team working to reduce professional isolation and disenfranchisement of practice nurses, and for practice nurses to actively contribute to local and national initiatives to improve spirometry services in the long term.

This research set-out to: a) investigate attitudes of disabled people (adults) toward other disabled people; and, b) attitudes of disabled people toward different impairment groups. Comparative data from a non-disabled sample was also collected. Two new attitude rating scales were developed for this research: the General Attitude Scale Toward Disabled People (GASTDP) and the Attitude Toward Impairment Scale (A TIS). Both scales achieved acceptable levels of internal and external reliability. Positive attitudes toward disabled people were found from both the disabled (M = 41.08; n = 193) and non-disabled samples (M = 39.29; n = 120). However, a hierarchy of impairment also appears to exist, with the disabled sample producing a rank ordering of most accepted to least of Deaf, Arthritis, Epilepsy, Cerebral Palsy, HIV/AIDS, Down's Syndrome and Schizophrenia. The nondisabled sample rank ordering was the same for five of the seven impairment groups, with only Cerebral Palsy and HIV / AIDS being placed in reverse order. The GASTDP contains two sub-scales (Subtle and Blatant Prejudice subscales). Statistically significant results between the two sub-scales were found for both the disabled and non-disabled samples, suggesting people tend to hold subtle forms of prejudice toward disabled people. The discussion therefore utilises the term aversive disablism, based on aversive racism. This theory argues that whilst people may be reluctant to express negative attitudes toward disabled people, they may also support policies that are disablist, i.e. segregated housing. The contact hypothesis, whereby contact with members of a minority group influence attitudes, was not supported by the data. This thesis recommends further research into subtle forms of prejudice toward disabled people from an in-group perspective and attitudes toward different impairment groups.