This study investigates all graduate entry to nursing in England, focusing on the perceptions and experiences of nursing students and health professional educators at one English university. It presents a history of nurse education, debates the cases for and against the move to an all graduate entry, and introduces a conceptual framework based on the influences on, and expected outcomes of, the undergraduate nursing student. The study adopts a single-embedded case study design. Data was collected between October 2012 and September 2014 using questionnaires and focus groups. Statistical analysis and thematic analysis (using the framework devised by Braun and Clarke, 2006) were undertaken on the quantitative and qualitative data respectively. The undergraduate student nurses reflected a positive attitude towards nursing, seeing a therapeutic relationship and the values underpinning ‘compassion in practice’ as fundamental to the role of Registered Nurse (RN). They also demonstrated motivations that reflected these principles and, to some extent, recognised them in themselves. The importance of developing and demonstrating graduate attributes was acknowledged, but these were not seen to be as significant as the fundamental principles of what it means to be a nurse. The majority of health professional educators supported the move to an all graduate entry to nursing, with nurse educators being more in favour that their Allied Health Professional colleagues. There was also clear recognition that the role of the RN had changed and that RNs needed graduate attributes in order to manage the complexities of twenty-first century healthcare. Participants in this study saw the move to all graduate entry as welcome and necessary, although this view was not universal. Reasons students gave for pursuing a career in nursing reflected those identified in earlier studies. The students’ experiences in clinical practice were affected by the standards of care they observed, the quality of mentorship and by issues related to ‘belongingness’. The study highlights and contributes to the on-going debate surrounding the development of nursing as a profession, confirming that the ideals of altruism have not been lost in the development of academic processes and identity.

This qualitative study explores spiritual issues in relation to coping with loss in situations of chronic and terminal illness. An Heideggerian hermeneutic phenomenological approach was chosen as the most appropriate methodology for exploring nurses’ lived experience of utilising spirituality as a means of helping patients cope with loss. My prior knowledge both brought me to the subject of study and influenced my interpretation of data. To ensure transparency of method this prior knowledge is outlined in my fore-structure of understanding. A purposive sample of 12 registered nurses, 5 from hospice, 4 from community practice and 3 from a nursing home setting participated in semi-structured interviews. A stepped process of analysis of interview texts produced overarching themes which are illustrated with excerpts that collectively produce a ‘thick enough description’ intended to facilitate understanding of my interpretation of data by those who chose to read this study. Findings were illuminated by drawing on existing theoretical knowledge and concepts. My research diary and notes at interview constituted a research journal that recorded how my knowledge and understanding developed through my reflection on, and reflexive response to interview data. In this way my research journal was used to illuminate the research process. There are an increasing number of studies that consider spirituality in healthcare and how patients’ spiritual needs can be recognised and fulfilled. However, this study provides a different perspective, in particular, examples of how nurses’ development as persons may render them not only a spiritual resource in themselves, but also, contribute to how they become proficient in spiritual care in situations of loss. There were four overriding ways in which the development of this aptitude was evident. Firstly, belief provided them with a means of coming to an understanding of why things happen and so helped them accommodate repeated exposure to patients’ grief. Secondly, being a spiritual carer involved establishing a relationship with patients through ‘connected’ communication. Thirdly, becoming proficient in spiritual care was reflected by an increasing maturity in engaging with patients’ real life and death issues, which was sustained by taking ‘time out’ to reconnect with the self. Finally, belonging to a team whose culture reflected a spirit of reciprocal support was crucial when patient care was emotionally demanding.

The purpose of this study is to explore how students' nurse identity has developed over the years and the particular role that disciplinary power has had in shaping it. The research focus was the School of Nursing in Jersey from 1924-2015. The study site included the wider social space where nurse education occurred at the School of Nursing; that is the classroom, the practice area and the nurses' home. The study attempts to fill a gap in local nursing history by creating a unique record while also considering the wider social influences on how students develop a nurse identity. The primary data comprises interviews with fifteen (n=15) participants who provide an historical account of their experiences as students. Interview transcripts and diary narratives with a further four (n=4) former nursing students from the earlier period are also included. These are supplemented with documentary archive material in the form of hospital student nurse records, newspaper archives, Societe Jersiaise archives, personal correspondence and photographs. Foucault's (1979) concept of panopticism was used to explore how the functioning of disciplinary power promoted the notion of docility and shaped the developing nurse identity of students. The Foucauldian framework provided a sociological analysis of disciplinary power and how the unconscious conditioning of students created the "docile body". The main themes identified relate to freedom (or not) of choice in choosing a career, shifting modes of control, control through the use of time, knowing your place, sister's "gaze" as a panoptical figure, living and working by the rules, fear of punishment, the gendered nature of nursing as an occupation, medical dominance, and the support from fellow students. The technologies of surveillance, normalising judgement and examination were employed to understand how, as student nurses, the participants internalised the values, beliefs and behaviours experienced in the School of Nursing. Tracing these technologies of discipline from the beginnings of the School of Nursing to its present day amounts to what in Foucauldian terms is a history of the objectification of the present. Findings indicate that discipline was a means of constructing experience and served to shape the identity of the participants as student nurses. It was easier to recognise Foucault's (1979, 1995) concept of panopticism in the traditional nurses' accounts; how this applied to the contemporary setting was less obvious but nonetheless apparent. While there has been more discreet monitoring of students in recent years, the methods of surveillance remain rooted in Foucault's (1979, 1995) representation of panopticism and the construction of the "docile body". Control was exerted over their lives in the classroom and on the wards. As students the participants began to regulate their own behaviour and discipline themselves. The historical perceptions of what it means to be a "good nurse" impacted on their developing identity across the years. The unconscious conditioning of the students served to create the "docile body" of the student nurse and this impacted on the development of an identity. Having identified the importance of the influence of disciplinary power, further research exploring this among student nurses in the contemporary university setting could make a positive contribution to understanding how this moulds a nurse identity.

Background: Choice has become the defining characteristic of service users’ relationship with the National Health Service (NHS) in the UK. Decades of market-orientated policy have encouraged greater customer focus, and the NHS is now subject to the same consumer drivers that can be identified elsewhere in society. Aim: The aim of this study is to understand whether the introduction to the NHS of market reforms designed to encourage and improve choice and experience have influenced the way in which service users access care and interact with service providers when receiving it. Method: This study utilises an ethnographic approach to data collection combined with the structure, theoretical under-pinning and replication logic afforded by comparative case study. Both approaches allow for the inclusion of qualitative and quantitative data and use multiple data collection instruments in a triangulating fashion. Two minor injury units (MIUs) were selected as research sites/cases since they serve a large community with multiple and diverse needs and provide a crucial stepping-stone between primary and secondary care services. Results: Although very few service users at either case identified themselves as ‘customers’ or ‘consumers’ of healthcare per se, there was general consensus that high standards of customer service were both important and desirable in a healthcare context. Similarly, regardless of whether service providers believed that service users should be viewed as ‘customers’ or ‘consumers’ of healthcare, they consistently demonstrated modes of behaviour that treated them as such. Conclusions: Through careful analysis of the data, it is possible to identify five different healthcare consumer typologies: passive, reluctant, assertive, pragmatic and knowledgeable. The broad range of views and positions demonstrated by these typologies in relation to healthcare consumption seem to be the result of social values and practises that have developed in response to consumer culture and society as well as previous experience of healthcare services.

The current position of the World Health Organisation (WHO, 2014) is that there is a threat of a global “obesity epidemic” (Boero, 2007, p.1); and existing studies in the UK report that a 5th of pregnant women are overweight. This has created increased scrutiny of fatness and weight, especially in pregnant women. The concern about obesity and pregnancy outcomes also contributes to the National Institute for Health Care Excellence (NICE, 2010), recommending that the antenatal care delivered to overweight pregnant women should be within the guidelines of a high-risk pathway of antenatal care. This has increased the medicalisation of the care for overweight pregnant women. The aim of this study is to explore the experiences of overweight pregnant women in relation to their heightened medicalised antenatal care. Using a social constructionist approach and a Foucauldian interpretive lens, semi-structured face-to-face interviews were used to collect data from 12 women who were between 16 and 30 weeks pregnant, 6 midwives who provide antenatal care for them, and 3 obstetricians to whom women are referred. The data were analysed using thematic analysis. The findings show that pregnant women do not identify with being ‘obese’ and perceive themselves as being overweight but healthy. Key themes that emerged from the data describing women’s perception of heightened antenatal care are: their understanding of risk and risk perception, the power of science and how it constructs their maternal health and the power of obstetricians justifying medical interventions in pregnancy and childbirth. This study creates and contributes to the awareness of how overweight pregnant women who are healthy experience antenatal care. It explores the need of overweight pregnant women, and identifies changes that need to be made to positively enhance how these women experience pregnancy and childbirth. These findings need to be considered by policy makers, individuals in practice and those with a role in educating health care practitioners so that overweight pregnant women are provided the appropriate antenatal care.

Aim of the thesis: To report on a study to describe and explain the contribution of registered nurses’ and care assistants’ to hospitalised patients’ mobility rehabilitation. Background: Studies internationally have shown that older adults often experience a decrease in their ability to mobilise during and after hospitalisation. Rehabilitation nursing interventions could be important in maximising the functional abilities of this population. Methods: A grounded theory approach structured data collection and analysis. Data were derived from three hospital settings (general rehabilitation, spinal injuries and stroke rehabilitation) and included 39 staff interviews and 61 hours of observation. Findings: Mobility rehabilitation is an ‘embedded activity’ and is achieved indirectly when nurses and care assistants transfer patients safely from one place to another. These events are described as ‘A to B transfers’. Practitioners perceive distinct differences in the process and purpose of ‘A to B’ transfers in comparison to ‘therapeutic handling’ activities undertaken by physiotherapists and occupational therapists. The core category for the grounded theory (Care to keep safe: Safe to care) is used to explain the findings. Conclusion: Theoretically, the nursing team could implement more structured intentional strategies’ to promote patients’ mobility rehabilitation. However, teamworking arrangements and work environments do not facilitate this.

In 1975, the medical staff at Glasgow's Western Infirmary suggested a study of patients making frequent and inappropriate use of the hospital IS acute receiving area. The staff claimed that these patients seldom had acute medical problems; they wasted the doctors I time; and consumed a substantial amount of hospital resources. The staff wondered what prompted the behaviour of these patients and whether they could be better managed in the future. In order to identify the frequent and inappropriate users of the acute receiving area, we reviewed the past acute attendances of the 3,284 patients in our patient sample. As we had no objective measures of inappropriate patient behaviour, we used the frequency of presentation as our sole selection criterion. knowinq that any frequent and inappropriate users would thereby be included. After samplinq the patient records. we defined frequent attendance as six or more acute attendances between 1st January 1970 - 31st July 1975, a 5 year 7 month study period. We found 150 (5%) of the 3,284 patients studied had been frequent attenders. We looked for ways to identify the frequent attenders at presentation but found no significant difference in age. sex. or presenting complaint between the frequent attenders and the 3.284 patients sampled. We then used these characteristics (age. sex, and presenting complaint) to select matched controls from the patient sample for each of the 120 frequent attenders who proved available for interview. We found inappropriate use of the acute receiving area mentioned in all but two of the 120 frequent attender records and 68% of the frequent attenders' acute presentations were attributed to inappropriate patient behaviour. While few (12%) frequent attenders were diagnosed as having greater medical problems than their matched controls, psychological problems were diagnosed in 77% of the frequent attenders in contrast to only 22% of the controls. The patients· answers at interview showed frequent attendance strongly associated with a number of background variables, with no single variable proving pathognomonic of frequent attenders. We found that, on average, the frequent attenders had greater health, housing, and employment problems, greater difficulties in relating to others, and were more accident-prone than their matched controls. We found most of the acute receiving area costs to be fixed costs and thought little would have been saved had the frequent attenders not presented. We thought the amount of hospital resources consumed by the frequent attenders was too small to. adversely affect other patients. Our study showed that a small number of frequent and inappropriate users of the acute receiving area indeed existed at the Western Infirmary. However, we thought that little could be done either to alter the social and psychological factors we found associated with frequent attendance or to prevent future acute attendances by these patients. At a hospital level, we thought the costs and risks involved in excluding the frequent attenders were outweighed by the benefits of simply treating these patients. At a community level, we thought that seeing the frequent attenders on demand in the acute receiving area was an efficient and relatively inexpensive way of supporting and maintaining these patients in the community.

This thesis describes an action research study that took place in the context of increasing intervention by UK central government in the shaping and delivery of health services, and broadening expectations about who could deliver services. The study was aimed at exploring the issues arising from the development of the interprofessional care co-ordinator (IPCC) role in an acute in-patient setting. The role was new, introduced with an inherent flexibility that enabled IPCCs to speed patients through their in-patient stays as fast as clinically possible. None of the four IPCCs appointed held a registrable qualification in health or social care. A review of the literature identified that very little is known about care co-ordinator roles in practice, particularly those held by non-registered workers. The study reported in this thesis began two years after the IPCCs took up post. The study’s objectives were to describe the characteristics, impact, issues and influences on the role. A wide range of qualitative and quantitative data were gathered and analysed between October 1998 and July 2000 within the framework of an action research approach. The findings identified that the IPCC role had informally shifted over time to take up the complex discharge planning work previously carried out by nurses. This shift was not reflected in Trust policy and had not been accompanied by a review of training, regulation or supervision. This had led to situations of risk for some patients. The findings threw light on contextual factors that enabled the role shift and disrupted the reflective leadership and long-term overview needed to monitor and respond to the shift. These factors included nursing staff shortages and a turbulent environment for managers characterised by multiple pressures, top-down targets particularly for acute efficiency, and high managerial turnover. In addition, nurses did not perceive that they had an influence on the ongoing development of the IPCC role. The findings support Abbott’s (1988) theory that an occupational group can take up the discarded work of a higher status occupational group, but challenge the theory that the work discarded is always more routine than the work retained. They support theories of a growing challenge to the primacy of professional knowledge and the existence of an organisational culture in the NHS in which there are broader expectations of who can deliver which health services. They also indicate that role substitution can lead to the routinisation and marginalisation of aspects of patient care. The findings also illustrate how an innovation can continue to be re-invented following its establishment into routine practice, and how the journey of an innovation can be influenced by its context. The findings throw light on a role in practice that is a cameo of current policy on new roles and have a number of implications for practice, policy, education and research.

Background: The social consequences of having a stroke can be severe, with social isolation a reported problem. It is little explored, however, what factors predict who will feel well supported and retain a strong social network after a stroke, nor is it well understood why friendships and other social contacts are lost. Aims: This thesis explored: 1) how social support and social network change over time following a stroke, and whether this is different for those with aphasia; 2) what factors predict perceived social support and social network six months post stroke; 3) why people lose contact with friends, and whether there are any protective factors; 4) how the changing dynamics within the family unit are perceived by the stroke survivor. Design and setting: Repeated measures cohort study. Participants were recruited from two acute stroke units and assessed at two weeks (baseline), three months and six months post stroke. A subset of participants was selected for in-depth qualitative interviews 8 – 15 months post stroke. Measures and methods: Stroke Social Network Scale; MOS Social Support Survey; General Health Questionnaire; National Institute of Health Stroke Scale; Frenchay Aphasia Screening Test; Frenchay Activities Index; and the Barthel Index. Multiple regression, ANOVA, correlation and t-tests were used as appropriate. Results: 87 participants were recruited of whom 71 were followed up at six months. At six months, 56% of participants were male, 16% had aphasia, and the average age was 69 years old. 29 participants took part in qualitative interviews. Perceived social support at six months was not significantly different from pre-morbid levels; social network, however, did significantly reduce (p = .001). Those with aphasia had comparable levels of perceived social support but significantly reduced social networks (p < .05) compared to those without aphasia. Concurrent predictors of perceived social support at six months were: a person’s social network, their marital status, and their level of psychological distress (adjusted R2 = .37). There was only one baseline predictor of social support at six months: perceived social support prior to the stroke (adjusted R2 = .43). Concurrent predictors of social network at six months were: perceived social support, ethnic background, aphasia and extended activities of daily living (adjusted R2 = .42). There were two baseline predictors: pre-morbid social network and aphasia (adjusted R2 = .60). There was a significant reduction in the Friends factor of the social network measure (p < .001). The main reasons for losing friends were: changing social desires especially a sense that many participants were ‘closing in’ on themselves; aphasia; loss of shared activities; reduced energy levels; physical disability; environmental barriers; and unhelpful responses of others. Family were generally robust members of the social network post stroke. The spouse was the main provider of all support functions. Nonetheless, beneath the apparent stability of the quantitative data there were changes in how family relationships functioned, including some distressing role shifts, for example, receiving rather than providing support. Conclusion: Contact with family and perceived social support remained stable post stroke. In contrast, a person’s social network, in particular contact with friends, was found to reduce, especially for those with aphasia. Indeed, aphasia was the only stroke-related factor at the time of the stroke that predicted social network six months later. Intervention aimed at addressing social isolation may be most effective if it takes into account the multiple reasons for friendship loss, including new language and physical disabilities, as well as changing social desires.

Domestic abuse is a public health issue with long term health and social consequences for its victims. The prevalence of domestic abuse among women seeking healthcare is higher than in the general UK population and often begins or worsens in pregnancy. Health visitors, because of their role with pregnant women and mothers are in a key position to offer both supportive interventions and to play a preventative role in domestic abuse. The aim of this research is to improve understanding of issues health visitors face when working with Pakistani mothers living with domestic abuse. The study is set in the north of Britain in an area that has experienced chain migration and settlement from the Mirpur and Faisalabad regions of Pakistan since the 1970s. Taking a qualitative approach and informed by a critical realist perspective, first-hand accounts from health visitors working in the area are used. The findings of the study confirm that domestic abuse perpetrated against some Pakistani mothers is a complex aspect of health visiting practice compounded by deep rooted cultural and social practices within many Pakistani families. The key challenge health visitors face appears to be non-disclosure of abuse by many Pakistani women and the main approach taken by health visitors in this situation is predominantly one of harm minimisation. Inconsistencies in practice were however noted. Three overarching themes were found from the analysis of the data which depict the challenges health visitors face and the endeavours they take to keep women safe. The theme of Presence depicts a range of actions linked to ‘seeing’ or ‘being with’ women and includes carrying out repeated enquiry into abuse. Role Strain describes how the health visitors express difficulty in fulfilling the various demands and expectations of the role. The term Covert Actions encompasses a range of seemingly hidden or concealed activities undertaken by health visitors in an endeavour to maintain Presence. The study provides useful insight into the forms of evidence many health visitors deem can legitimately inform their clinical interventions when working with this population group and succeeds in extending current understanding of the types of knowledge health visitors draw from to inform their decisions in this specific area of practice. It also provides awareness of the wider challenges health visitors can encounter when working more generally among collectivist and honour-based communities and raises questions about some of the philosophical assumptions usually associated with Western models of healthcare. Implications for practice are that mainstream domestic abuse interventions should be used with sensitivity to the different cultural contexts in which many Pakistani mothers live, and attempts should be made to develop appropriate interventions that derive from those contexts. This includes holistic assessment tools that are flexible enough to allow clinical judgements to be informed by the more subjective elements of evidence gathering and which take into consideration the impact of the multiple oppressions some women encounter. Recommendations for service providers are that they should take a broader view of domestic violence that recognises ‘difference’ and therefore enables health visiting interventions to be flexible and responsive to differing need. This includes considering more community-based interventions among certain population groups.