Background: Dysphagia is common after stroke, so feeding through a naso-gastric (NG) tube may be necessary. NG tubes are frequently dislodged, potentially causing feed or fluids to enter the lungs. Interventions to prevent this include taping NG tubes to the face, hand mittens and nasal bridles. Overall Aim The aim of this study was to explore the opinions of staff, patients and relatives about the maintenance of NG tube feeding for stroke patients while investigating current clinical practice. Research Design and Methods: A three-phased mixed method design was used. Phase 1 involved focus groups with multidisciplinary stroke unit staff (n=17); one-to-one interviews, with stroke patients (n=4) and relatives (n=6). Phase 2 incorporated a postal survey sent to a convenience sample (n=528) registered nurses working in the field of stroke across the UK. Phase 3 involved interviews with nurses (n=5) outside the speciality of stroke. Findings: Phase 1 highlighted many categories, including: lack of protocols; ethical and legal concerns; training to insert NG tubes; patient dignity; patient autonomy and potential harms and benefits of interventions used. There were variations in the opinions of staff, patients and relatives concerning the effectiveness and acceptability of methods for securing NG tubes. Phase 2 achieved a response rate of 59% (n=314/528); 22% (n=68/312) of nurses used hand mittens, only 11% (n=34/312) used a protocol; 56% (n=176/314) of nurses had received formal training to insert an NG feeding tube, more senior nurses had been formally trained than junior nurses (p<0.005). Acceptability and effectiveness ratings for tube securing interventions varied: 50% (n=158/312) considered hand mittens to be unacceptable. However, from a total of n=92 responses about their effectiveness, 66% (n=61/92) felt they were effective. Phase 3 produced more detailed results about fear associated with NG feeding; inconsistent approaches to training and ethical and legal issues of patient restraint. Conclusions: Overall this study demonstrates differences in opinion about what constitutes acceptable, effective and legal practice when maintaining NG feeding for stroke patients. It also suggests that the lack of consistent nurse training affects the standards of care patients receive. Furthermore, there is a need for more robust evidence to inform clinical practice. This study culminates in a model of nursing related to the insertion and maintenance of NG feeding for stroke patients.

The aims of this research study were threefold. Firstly, to explore the impact of the strategic arrangements and mechanisms to implement and support practice based learning. Secondly, to investigate the selection processes, preparation, support and evaluation of mentors. Thirdly, to explore the impact of mentorship from the viewpoint of mentors, students, managers and educational links within the clinical learning environment. The study design incorporated both quantitative and qualitative approaches involving a three phased approach engaging three regional sites. The first phase involved a quantitative approach using a survey. Phase one data arose from senior staff in Higher Education Institutions (n = 10) and the National Health Service (n = 22). The results from the survey, which focused on the strategic implementation of practice based learning and the preparation of mentors in Scotland, were used to inform phases two and three of the study. Phases two and three of the research study used a modified grounded theory approach. A range of data collection methods were used to gain information from mentors, Link Lecturers, Practice Education Facilitators, managers and students. Data collection and analysis for phases two and three occurred simultaneously and incorporated the constant comparative method of analysis. Phase two provided data from interviews with mentors across the three regional sites giving a total of 30 with ten participants in each site. Focus groups were conducted with Link Lecturers (n=17); Practice Education Facilitators (n=13); ward managers (n=21) and third year student nurses in the adult branch of the undergraduate programme (n=34). Three major categories were developed ‘Becoming a mentor to facilitate learning in practice' ‘Operationalising the facilitation of learning in practice', and ‘Quality infrastructure optimising learning in practice. From these major categories a core category emerged. The core category ‘Strategic Engagement for a Quality Learning Experience in Practice' captured the process that mentors, Link Lecturers, Practice Education Facilitators, managers and students perceived as their experience related to the clinical learning environment. A tentative theory emerged which addresses the gap between strategy and operationalisation in order to enhance the learning experience in practice. The emerging tentative theory is closing the strategic and operational gap: strategic engagement for a quality learning experience in practice. A model is provided to illustrate how to manage the interface in order to provide quality learning in practice. The study provided useful insight into learning in practice and the roles of staff within the clinical learning environment with how learning maybe more effectively managed and strengthened.

Over the past 30 years, Senior and Advanced Nurse Practitioners (SNPs/ANPs) have been introduced into the healthcare arena across the world. The international literature reports such roles have created tensions within healthcare systems (Smith 2000; Tye & Ross 2000; Scholes & Vaughan 2002). However, over the past three decades the root causes of such tensions remain still to be addressed. The literature reports the consistent entrenched reluctance to collaboratively engage with SNP/ANP roles (Cummings et al. 2003; Reay et al. 2003; Davies 2006). This led to the aims of my Constructivist Grounded Theory (CGT) study, which were to discover why there continues to be tensions surrounding Senior and Advanced Nurse Practitioner roles in healthcare, in addition to attempting to generate a substantive theory to provide a foundation in which a hypothesis could be tested across a wider arena. Arising from these aims were three research questions which were explored in three phases. The first research question, posed in phase 1, was ‘where are tensions created by Senior and Advanced Practitioner roles from a service user and healthcare team perspective?' This led to in-depth interviews taking place with service users (n=12) and members of the healthcare team (n=18). Theoretical sampling consisted of medical staff (n=9), nursing staff (n=7) and Allied Health Professionals (n=2). Data were considered saturated when no new data could be identified and the main categories with focused codes were coherent. The second research question, posed in phase 2 of my study, was ‘where do tensions remain apparent in service and what meanings and actions are attributed to them?' The method of Grounded Theory Ethnography was employed, which gave priority to interactions rather than the setting. This method consisted of a 3 stepped approach, employing participative observation and individual interviews. In total, 13 periods of observation were undertaken, which equated to 64 hours of observation within different sites. The emergent categories from this phase built upon the categories from phase 1. In phase 3 the research question posed was ‘what are the interpretations of Senior and Advanced Nurse Practitioners on interactions with the healthcare team and service users?' Six focus groups and one paired interview enabled the development of the core category “Status Games”. This subsumed the main categories from each phase and incorporated common themes and patterns across all data. This core category was further verified with five individual interviews and no new properties emerged. This core category reflected the data across all phases effectively. Interpretative theorising incorporated advanced memos across all 3 phases of my study and enabled the development of a substantive theory. Social psychological game theory and underpinning script theory, which is part of the Transactional Analysis Paradigm, provided the theoretical lens to interpret what was grounded in the data. This led to the development of two new concepts, the first was status games which incorporated game analysis and highlighted ulterior transactions which have not been previously reported in the literature. The second was the professional script concept, which it is theorised underpins status games. This is also new and has not been conceptualised in the Transactional Analysis or healthcare literature. This theoretical framework illustrated that status games which fulfil professional script are being played out with awareness. It is proposed that by recognising these concepts, this will reduce tensions with SNP/ANP roles and lead to improved patient-centred care. As Vandra (2009) reports by recognising the processes and actions of communication it is possible to bring ulterior transactions into full awareness and prevent games, thus problems with communication. This led to the development of the substantive theory in this study which is: ‘The tensions generated by SNP/ANP roles stem from playing status games to fulfil professional script which requires to be recognised and acknowledged by the healthcare team in order to change the status quo and culture'. Whilst social psychological game and script theories can provide an underpinning understanding of social games and life scripts for individuals, the status game concept which emerged from my study expands our knowledge and provides a unique understanding surrounding the impact of professional script in healthcare organisations. It is hypothesised that this script has led to status games, which is central to the tensions surrounding SNP/ANP roles.

Patello-femoral joint syndrome (PFJS) is a common problem that is challenging to treat. The dominant theory of its aetiology is „patellar malalignment‟, in which the vastus medialis oblique (VMO) muscle is ineffective in controlling patellar position but this is based on assumption. The Q-angle, a frontal plane measure, indicates patellar position relative to the pelvis and tibia; however, there is no standardised measurement protocol and it is assumed to be a fixed value. The work reported highlights the tension between measurement rigour and clinical utility. Valid measurement of the Q-angle and VMO muscle were established using: motion analysis, magnetic resonance imaging (MRI) and ultrasound imaging, in recreationally active healthy participants, then applied in various experiments involving people with PFJS, with the following conclusions: The Q-angle: * varied over 60 seconds in relaxed standing * exhibited differences in movement patterns of the three markers which form the Q-angle between healthy and PFJS groups during the stance phase of gait * was generally at its maximum at the beginning of the stance phase of gait and at its minimum at the end * did not correlate with pronation at the sub-talar joint VMO muscle size: * linear and CSA measures of the VMO muscle correlated well * measures of VMO muscle size from ultrasound were shown to be valid when compared with MRI and were equally reliable No correlation between the Q-angle and VMO muscle size was found. These results increase our understanding of the usefulness of the Q-angle, particularly its natural variation of between 30 and 40 in static standing and its different movement pattern during gait in PFJS. It was established that ultrasound imaging provides valid measures of VMO muscle size and the relationships between its CSA and linear dimensions were characterised.

This research examines the transition from student nurse to Registered Nurse (child). Earlier studies suggest the transition always involves a period of discomfort and uncertainty. However, there is a dearth of longitudinal studies of children‟s nurses, revealing a gap in the evidence that this study aims to fill. This longitudinal study commenced in one HEI in England where the six participants were completing their undergraduate programme in child nursing. A phenomenological interpretive design was used to answer the research question: „What is the experience of making the transition from student to RN (child) like?‟ Data was collected using focused qualitative interviews at three stages: mid final year, and at 3–4 months and 12–14 months post-employment as an RN. The data was analysed using descriptive and interpretive methods. The thesis draws out the changes in the participants experience over time and suggests the transition extends beyond the first year of practice. It involves development within four overarching themes: Personal and Professional Identity, Primacy of Practice, Working with People, and Managing Newness. These key themes are present across the participants‟ experience but their importance changes over time. The transition is characterised by the visibility of being a nurse and the invisibility of being a „new‟ nurse. This study supports the findings of some earlier studies and introduces some new evidence in relation to children‟s nursing, such as responding to crises, coping with grief and the difficulties and challenges of working with parents. The main limitations are that this is a small-scale study within a specific branch of nursing, with participants drawn from one HEI and conducted by a single investigator. However, because the participants took up employment in different locations in England, the findings may have some resonance with other neophyte children‟s nurses beyond the original setting of the research. Recommendations are made for undergraduate programme providers and employers to strengthen and develop the preparation of RN (child) pre- and post-qualification, particularly in the areas of preceptorship, prioritising care and managing time, working with parents, and coping with emergencies or the death of a child

This study focuses on the practice component of United Kingdom (UK) pre-registration nurse education. In particular, the research has concentrated on one school of health - part of a larger higher education institution, in the UK and has explored how the institution ensures the quality of the practice component of two of its pre-registration nurse education programmes, the Adult and Mental Health branch programmes. A ‘Major Review’ inspection of these programmes was undertaken in 2005 as part of the requirement of the Quality Assurance Agency (QAA) (2001). The research analysed whether the precepts that relate to the practice component of the school’s pre-registration programmes were being implemented, enacted and experienced by those engaged in them. To achieve this Yin’s (2003) qualitative case study approach was adopted, involving interviewing senior lecturers (n=9), mentors (n=7) and student nurses (n=8) and undertaking in depth analysis of relevant documentation. The findings identified that the precepts themselves did not directly influence what the link tutors and mentors did. As a result, the student nurses experienced different levels of support from link tutors and mentors. This prevented students from experiencing a standardised approach to the practice component of the programmes studied. From this it has been concluded that the ethos of the Major Review process has had no long term impact with regards to standardising and quality assuring the practice component of the programmes studied, a finding that has not been formally reported elsewhere. Instead individual values, beliefs and practices dominated the way in which the players studied operated. The study also highlights how broad and non-descript the precepts themselves are in guiding the school towards a standardised approach to the practice component of the programmes in question. All but one of the precepts ‘Staff Development’ were evidenced as being implemented and/or experienced. Having researched the placement learning precepts (QAA 2001) in their entirety, which has never been done before, it became evident that whilst the content of all of the precepts had been included in the documentary data studied (Clinical Assessment of Practice Documents, School Plan and Pathway Guide), this did not guarantee that all of the precepts were fully implemented and enacted by relevant players. This was because the instruction and guidance within the documents studied were often broad and non specific, to which the design of the precepts allowed. The outcome of this enabled a) link tutors to interpret their roles and responsibilities in different ways; b) theory practice gaps to emerge, which ranged from weak partnership relationships between link tutors and practice placement mangers; c) mentors and link tutors interpreting the CAPD differently and d) mentors mentoring and assessing students in different ways. This resulted in students nursing experiencing different types of learning opportunities and assessment practices that did not always match the learning and development that may be needed in order to practice as a competent and confident registered nurse, at the point of registration. Additionally, there was a lack of understanding by all players about local quality assurance systems and processes. This ranged from none of the participants being familiar with the complaints procedures, or being clear about how placement learning experiences were monitored and evaluated. As a result of these findings the competence of the personnel (link tutors and mentors) studied has been questioned. A phenomenon that highlighted that precept 6 ‘Staff Development’ (which required institutions to ensure that staff who are involved in placement learning are competent to fulfil their role), was not being demonstrably implemented or enacted. A series of recommendations have been designed to meet both the needs of the school studied and others similar. Some of the recommendations relating to the school studied have already been implemented with positive effect. This was evidenced when the researched school was confirmed as having an ‘Outstanding Level of Achievement’ for practice learning following a more recent quality assurance inspection by HLSP on behalf of the Nursing and Midwifery Council.

Lumbopelvic pain (LPP) is associated with altered abdominal muscle function yet few tools exist that enable physiotherapists to identify these changes in a clinical setting. Ultrasound imaging (USI) has potential however its ability to detect altered abdominal muscle function and associated changes in bladder base (BB) position during tests common to a physiotherapy assessment of LPP, has yet to be established. The aims of this research were to determine the validity and reliability of USI technique in a clinical setting, investigate the relationship between changes in abdominal muscle thickness and electrical activity, and compare sonographic characteristics of the abdominal wall, and BB position, between persons with and without LPP. Validity results indicate that 5o-10o of angular, and 8mm of inward/outward transducer motion don’t produce measurement error, and that transducer motion can be kept within these thresholds during two commonly used clinical tests; the Active Straight Leg Raise (ASLR) test and Abdominal Drawing in Manoeuvre (ADIM). Regarding reliability, measurements of abdominal muscle thickness, inter-recti distance (IRD) and BB position (healthy and LPP cohorts) during the ASLR and ADIM were good to excellent (within day ICC; 0.84-0.99, between day; 0.80-0.99). Crosscorrelation functions examining the relationship between changes in abdominal muscle thickness and activity during an ASLR and ADIM were low (r=0.22-0.40), and associated time lags large (-0.44-1.15s), suggesting that changes in muscle thickness represent more than changes in electrical activity. On comparing sonographic features between cohorts a series of features were identified that differed between the groups. Specifically, the LPP cohort had a thinner rectus abdominis (p<0.001), thicker perimuscular connective tissue (p=0.007), a wider IRD (p=0.005) and demonstrated smaller increases in TrA thickness (p≤0.00-0.05), and greater BB descent (p=0.02-0.03) during the ASLR. To determine if these sonographic features assist in discriminating LPP a statistical classification technique was piloted. Preliminary results identified a set of 14 sonographic features that classified LPP participants with 84% accuracy. These findings support an argument regarding the clinical value of USI and serve as the basis for future investigations aimed at determining if USI enhances the assessment, and ultimately treatment, of individuals with LPP.

Mobility in later life can take various forms, as a result of changes in personal circumstances, such as physical impairments and driving cessation. Therefore, understanding the concept of mobility in later life is complex and challenging. Through an interdisciplinary qualitative approach, this thesis examines the role of information and communication technology in supporting mobility and independence in later life. The research highlights a gap in the theoretical understanding of the concept of mobility, and uses insights from the three thematic areas of transportation, technology and older people, as well as key concepts such as social inclusion and independence, in order to develop a new conceptual framework to study mobility in later life. Research that brings these three areas of transportation, technology and older people together, is largely absent from the study of mobility. The research methodology included two phases of data collection. Firstly, the Mobilisation and Accessibility Planning for PEople with Disabilities (MAPPED) project, which focused on the field trials of tailored handheld navigational devices by older people; and secondly, the Getting Out and About project, which involved older people participating in in-depth semi-structured interviews with hypothetical vignettes. The results highlight the importance of mobility in maintaining independence in later life, whilst recognising the heterogeneity of older people by demonstrating a variety of attitudes, experiences and perceptions towards travel behaviour and information and communication technology in later life. The thesis argues that through the facilitation of virtual mobility, such technologies can offer older people an important alternative to physical mobility, which can be further explored in the future design and implementation of policies aimed at supporting older people and improving their well-being and social inclusion

At least one patient will experience a potentially serious intravenous (IV) drug error every day in an ’average’ hospital. IV drug errors have been estimated to be a third of all drug errors. Previous drug error research has focused on observation of nurses and errors they make but has not attempted to understand the decision-making processes used during the preparation and administration of IV drugs. The aim of this study was to explore the decision-making processes that novice and experienced IV nurses use during IV drug administration and how this influences risk taking and errors. A three-phased ethnographic study was carried out in a specialist cancer hospital, using focus groups, observation and interviews. Three focus groups with 14 registered nurses were used to develop culturally relevant definitions related to error and experience. Observation of the two wards took place over a week each. Twenty nurses were observed preparing and administering IV drugs, and then interviewed about their procedure. Data analysis was carried out using a five stage approach. Definitions of drug error, IV drug error, novice and experienced IV givers were developed from the focus groups. Four major themes were identified and represent findings from the direct observation and interview of the nurses: interruptions; lack of identification/knowing the patient; routinised behaviour; prevention of errors. One of the key findings was the lack of checking of patient identity prior to IV drug administration, which appeared to be based on the nurses feeling they knew the patient well enough although this was in contrast to the checking of drugs even if they were familiar with them. Implications for practice included: exploring new and effective methods of education based on behavioural theories; involving staff in updating and writing policies and procedures; and formal assessment of staff during IV preparation and administration.

It is argued that healthcare governance should play an important role in the overall functioning and effective performance of hospitals. However, the literature is devoid of how healthcare governance influences the performance of hospitals in Africa and other developing countries. This study examines the effects of hospital boards and ownership structure on the performance of hospitals in Ghana. The study specifically examines the characteristics of hospital boards, ascertains whether the presence of a hospital board and ownership structure affect hospital performance, evaluates the effects of hospital board characteristics and ownership structure on hospital performance, and also investigates the interaction effects of hospital board characteristics and ownership on performance. Based on a sample of 132 hospitals, the study produces a number of results. First, the study indicates that 69% of the hospitals have a board in place. The results also show that all the mission hospitals have a board in place. Half of the public hospitals and 80% of the private hospitals also have a board. The hospitals with a board exhibit varying board characteristics. Using regression models, the results show that hospitals with a board demonstrate lower occupancy, higher discharge and deliver better quality healthcare. In terms of the effect of board characteristics on performance, smaller boards are associated with better health service quality and lower occupancy. Hospitals with greater proportion of outside board members assist management to be cost efficient and improve on their operations leading to higher discharge. The results also show that hospitals with greater representation of medical staff on the board perform better in terms of occupancy but are less cost efficient. Hospitals with CEO duality perform better in terms of efficiency. However, hospitals with separate positions for the CEO and chair perform better in terms of discharge and service quality. Additionally, the evidence suggests that boards with higher female representation deliver better quality of healthcare, resulting in higher discharge rate. Also, frequency of board meetings is associated with lower occupancy, higher discharge and improved health service quality. The results also show that mission-based and private hospitals perform better than public hospitals. Further, the results of the interaction effects suggest that mission-based and private hospitals with effective board governance exhibit better performance than public hospitals. This study makes a number of new and meaningful contributions to the extant literature and the findings support managerialism, stakeholder and resource dependency theories. The findings also have important implications for effective and efficient governance and management of hospitals.