Written by a full-time clinician, this thesis explores an example of ‘Big IT’ in healthcare, the National Programme for IT in the United Kingdom National Health Service. It is unique in exploring the interaction between people and information technology in the healthcare workplace, from an engaged standpoint within one of the National Programme’s implementation sites, in order to provide a critical and a socio-technical appreciation.

This thesis is about nursing work and the ways in which nurses in a general hospital accomplished occupational jurisdiction. It is based on ethnographic data generated on a surgical ward and a medical ward in a single NHS trust hospital. The study is set in the context of recent developments in nursing and medical education (DHSS, 1987; GMC, 1993; UKCC, 1987) and health policy (DH, 1989) which have created the impetus for shifts in the division of labour in health care, reviving deep-rooted historical tensions between professional and service versions of nursing. Drawing on the work of Hughes (1984), Abbott (1988) and Strauss and colleagues (Strauss et al, 1963; Strauss et al, 1964; Strauss, 1978) the aim of this project was to move on from the policy debates and develop a less essentialist account of the nursing role through an exploration of the ways in which nurses managed the parameters of their work in the course of their everyday activities. Hughes concept of 'dirty work' is employed as a sensitising device. The work of hospital-based general nurses is explored through the analysis of five key nursing boundaries: nurse-doctor, nurse-support worker, nurse-patient/relative, nurse-nurse, and nurse-management. The professional and sociological literature suggested that as a result of recent policy developments, there would be an increased need for negotiation of nurses' inter-occupational boundaries with medicine and support workers and that this was likely to be subject to some tension. But field observations revealed that nurses accomplished these inter-occupational boundaries with minimal negotiation and little explicit conflict. Conversely, there were policy-related tensions at the three other key nursing boundaries - at nurses' infra-occupational boundary, at the boundary between nurses and patients and their relatives, and at the boundary between ward-based nurses and nursing and general management - which were largely unanticipated.

The Mental Capacity Act (2005) (MCA) is part of the legislative framework of the NHS. Small scale studies in a range of health settings have shown that the understanding and use of the MCA (2005) varies considerably in different services and across staff of differing occupations and grades. The experiences of individual staff in using the MCA has received little attention. This grounded theory study aimed to explain how staff working with people with a learning disability (PWLD) make sense of and use the MCA, whilst also exploring the factors that influence applying the MCA in clinical practice. This study involved 11 healthcare staff from a specialist learning disability service that had used the MCA in the six months prior to their participation in the research. Staff interviews provided narratives about how they had used the MCA. A theoretical framework was developed from the analysis which underpinned three core conceptual categories. The first core category was that of ‘professional risk’ in which staff have awareness of a series of risks that pertain to themselves or the service user that could have negative professional or legal consequences. The second core category described ‘emotional risk’, which affected both the staff and service user. Staff appeared to experience those risks as feelings in the form of anxiety or concern. Both ‘professional risk’ and ‘emotional risk’ bring about ‘strategies’ which mediate the risk; allowing staff to justify and document their position, creating what feels like safe practice for both the staff and service user. Factors which facilitate the use of the Act are concerned not only with these risks but the significance of the decision that the service user has to make. The findings suggest that there is much uncertainty in the process of using the Act, some of which is due to the subjective nature of evidence gathering. The study suggests that peer support offers a range of factors important to education and development of experience in using the Act, along with helping staff cope with the outcome of decision making. The findings have clinical implications for those involved in managing difficult assessments and decision making, including how to gain an appropriate balance between risk and human rights against a backdrop of adversity that can be present for people with a learning disability. Further implications clinically and for future research, along with limitations of the study are also discussed.

The postnatal period is an important and extremely vulnerable time for new mothers and their infants. Research has outlined the considerable extent of maternal physiological and psychological morbidity following childbirth. The underreporting and undiagnosed aspect of this morbidity has also been highlighted. Newborn infants are totally dependent on their needs being met and are also at risk of newborn conditions particularly if they are undiagnosed, for example neonatal jaundice. There is however, mounting evidence regarding the lack of postnatal support from health professionals, with women continuing to report their dissatisfaction with postnatal care. Research into postnatal care is pre-dominantly quantitative and clinically focused. Few empirical studies have examined the meaning women give to their postnatal care experiences. This research aims to generate a deeper understanding of the meanings, and lived experiences of postnatal care. In addition, it aims to reveal future possibilities to enhance women’s postnatal care experiences. Initially, an in-depth examination of relevant literature is undertaken followed by a presentation of the process and findings from a qualitative meta-synthesis. An in-depth exploration of Martin Heidegger’s biography and explication of his philosophy is then outlined. This research is a Heideggerian hermeneutical phenomenological study of Irish women’s aspirations for, and experiences of, postnatal care. Purposive sampling is utilised in this research, which was undertaken in two phases. Phase one involved group interviews over three different time periods (between 28-38 weeks gestation, 2-8 weeks and 3-4 months postnatally), with a cohort of primigravid women and a cohort of multigravid women. The second phase involved recruiting two further cohorts of primigravid and multigravid women who participated in individual in-depth interviews over the same longitudinal period. In total nineteen women completed the study. Thirty-three interviews were held in total. The data analysis is guided by Crist and Tanner’s (2003) interpretative hermeneutic framework. The women’s aspirations/expectations for their postnatal care are represented through three interpretive themes: ‘Presencing’, ‘Breastfeeding help and support’ and ‘Dispirited perception of postnatal care’. In addition, five main themes emerged from the data and capture the meanings the women gave to their lived experiences of postnatal care: ‘Becoming Family’, ‘Seen or not seen’, ‘Saying what matters’, ‘Checked in but not always checked out’ and ‘The struggle of postnatal fatigue’. The original insights from this research clearly illuminate the vulnerability women face in the days following birth. A further in-depth interpretation and synthesis of the findings was undertaken. This philosophical-based discussion drew from the work of Heidegger (1962) and Arendt (1998). Engaging with these theoretical perspectives contributed to a new understanding about why some women within a similar context, have positive experiences of postnatal care while others do not. As such, the very nature that midwives and other postnatal carers are human beings has an influence on a woman’s experience of her care. These carers, in their exposition of ‘being’ have the ability to demonstrate ‘inauthentic’ or ‘authentic’ caring practices. It is those who choose to be ‘the sparkling gems’ that are the postnatal carers who make a difference and stand out from the others. For the women in this study, their postnatal care experiences mattered. While some new mothers reported positive and meaningful experiences others revealed experiences which impacted unnecessarily. The relevance of these findings, recommendations and suggestions for future research are offered.

The National Health Service (NHS) continues to go through a period of considerable transition as health services change to meet the needs of a 21st century population. Staff are acknowledged as key to such processes. Staff well-being is a key concept in organisational change literature. For example, levels of staff well-being can be used to measure the success of organisational change. Existing literature has established that a number of different features of change are associated with staff well-being such as levels of control and demand, and social support. The study presented here extends these relationships to focus on how and why staff well-being is influenced during organisational transition. An ethnographic approach was used to observe two surgical units, both of which were undertaking transitions by relocating to new purpose-built facilities. Findings are arranged around three different themes and within each theme a number of aspects of the change were found to be driving effects on well-being: 1) information and communication during transition: the extent to which change-related communications were consultative/participatory, well-scheduled, transparent and incorporated job-related technical information; 2) the nature of the transition: working with ‘unsuitable’ patients, working in restrictive and disconnected work spaces and the fast-paced nature of work; 3) the impact of the transition on social relationships: the presence of support structures and changes to team dynamics. This investigation contributes to improving understanding of what affects staff well-being during change. A number recommendations for best practice are subsequently formulated.

Individuals or groups will form impressions of another based upon a series of traits, which may be relied upon when forming behaviour pattern towards others (Asch, 1946; Crocker and Major, 1989; Pinel, 1999; Albon, 2002; Corrigan and Wassel, 2008). These traits will depict the reception individuals receive within healthcare and may depend upon learnt and inherited ‘perceived’ ideals affecting the working and personal relationships experienced by positively diagnosed healthcare workers, predisposing stigma responses to others (Asch, 1946). A mixed method study investigating the potential existence of stigmatising values from student nurses towards positively diagnosed healthcare workers with Pulmonary Tuberculosis (PTB), Human Immunodeficiency Virus (HIV), Methicillin-resistant Staphylococcus Aureus (MRSA), Hepatitis C and Diabetes type 2, was undertaken. Analysis provided exploration of the stigmatising attitudes and values of 482 student nurses undertaking an education programme. Interpretation of the findings explored the participants views at course commencement, midpoint and completion considering variables of education (theoretical and clinical), personal and professional influences. Findings indicated that stigmatising values and attitudes return to those identified precourse and underpin the need for implementation of a change to nurse education within this area. The development of a longitudinal education model for healthcare workers considering disease processes and influencing factors psychologically, socially and physically, will provide opportunities to reduce the existence of stigmatisation for positively diagnosed healthcare workers.

Treatment and advice on amoebic dysentery from case studies onboard H.M.H.S. Lanfranc, May 1916.

Waterbirths have been available in the United Kingdom as a method of pain relief for childbirth for over two decades but the neonatal safety of birth in water remains unevaluated. Opponents of a waterbirth randomised controlled trial state randomisation would undermine women’s childbirth experience. In addition, little is known about midwives’ attitudes to waterbirths. This thesis addresses some of the lack of evidence by reporting the findings of two studies which had three aims: to investigate the feasibility of a waterbirth RCT to assess the effects of a waterbirth on the neonate, to explore women’s thoughts about participation and whether randomisation affects women’s satisfaction with their childbirth experience and to assess midwives’ attitudes to waterbirths. The first study involved a RCT with a ‘preference arm’. Eighty women were recruited: 60 in the RCT and 20 in the ‘preference arm’. Women were asked to complete questionnaires to assess their expectations for, and satisfaction with, their childbirth experience: at recruitment, after the birth and 6 weeks after the birth. Women in the randomised arm indicated willingness to partake but questioned midwives’ commitment to offering waterbirths. A Q Methodology study was undertaken to identify factors which influence midwives’ (n=31) attitudes towards waterbirths. Four factors were identified: Motivation, Risk Assessment, Confidence, Safety. Conclusion: It is feasible to organise a larger RCT to assess neonatal safety and women would be supportive. Strategies would be required to ensure midwives are confident and supportive of the waterbirth service.

The primary aim of the thesis was to report new cost-effectiveness evidence in the clinical area of heart disease. Following a review of published empirical work, this was achieved by undertaking three new cost-effectiveness studies: one in nurse-led secondary prevention clinics for coronary heart disease in primary care, one on cardiac resynchronisation therapy with or without an implantable cardioverter defibrillator in chronic heart failure, and the final one on a new drug therapy, nebivolol, compared with standard treatment in elderly patients with heart failure. The second aim of the thesis concerned the application of modelling methodology, with the intent being the provision of general recommendations in using Markov modelling approaches in economic evaluation conducted in the heart disease area. The focus was on extrapolation of cost-effectiveness of an intervention beyond a trial both in terms of the time horizon of the analysis and in relation to the population involved. Fundamental issues in parametric distribution functions and Markov modelling approaches have been revisited, with detailed consideration of which parametric distribution functions should be employed when extrapolating beyond a trial and how they could be adopted into model-based analyses. The need for further methodology investigations in this area is discussed in conclusion.

This thesis explored the processes underlying interprofessional working relationships between midwives and health visitors in UK maternity services; using a multi method approach consisting of a systematic review, interviews, and focus groups. The systematic review synthesised the literature on midwife-health visitor collaboration, identifying barriers and enablers that are influential to successful interprofessional collaboration. Thus, the subsequent empirical studies attempted to explore these barriers and enablers in greater depth, from the perspectives of midwives and health visitors. Two studies utilised the Theoretical Domains Framework to explore the barriers and enablers to midwife-health visitor collaboration (Chapters 3 6). These are the first studies to examine midwives’ and health visitors’ perceived barriers and enablers to interprofessional collaboration using a psychologically grounded theoretical framework. Midwives and health visitors identified barriers and enablers to interprofessional collaboration across each of the 12 theoretical domains, such as ‘Knowledge’ (e.g. awareness of processes involved in contacting midwives) and ‘Memory, attention, and decision processes’ (e.g. contacting health visitors when there is a concern). Chapter 6 compared midwives’ and health visitors’ perceived barriers and enablers to interprofessional collaboration, and discussed its research and practice implications, including approaches to intervention development for improving interprofessional collaboration. For example, various behaviour change techniques can be integrated as part of interventions aiming to enhance interprofessional collaboration. The final empirical study attempted to address the gap in the interprofessional literature by involving service users’ views. Focus groups with recent mothers were conducted to gain explore their perspectives of interprofessional collaboration in maternity services. Findings suggest that women observe fragmentation between midwifery and health visiting. Participants recommended service changes including group based antenatal classes jointly provided by midwives and health visitors. In summary, the findings indicate that midwife-health visitor interprofessional collaboration is important to professionals and women, but will require health professional behaviour change along with service changes.