Introduction: Difficulties persist in conceptualising spiritual needs and understanding their relationship to religious needs and wellbeing in healthcare and particularly in nursing education. This research was undertaken to explore approaches and challenges associated with this area in undergraduate nursing education in England. Methods/Methodology: Using a systematic approach, a literature review covering the period 1993-2017 was undertaken to explore potential issues and challenges reported. Applying case-study methodology, data were collected from three university nursing schools from different parts of England. Sources for data triangulation within schools included, curriculum review of undergraduate nursing courses, exploring the views of nursing educators through semi structured interviews and focus group studies with nursing students. Template analysis was used to identify themes in the data. Findings: Due to the module based curriculum, the integration of spirituality in nursing education appeared to be treated as a matter of personal choice and convenience rather than as an essential domain of teaching and learning practice in England. Owing to conceptual complexity, addressing religious needs was often considered to be synonymous with addressing spiritual care need. Factors were identified contributing to the difficulties in the issue of educating nurses in this area. These were: lack of clarity in curriculum documents; uncertainty as to how far nurses should address these issues and how far this was a specialist chaplaincy function; fear of being judged or rejected in a multicultural environment; and the dominance of disease-centred care. The participants voiced a desire for developing a shared understanding through developing a more explicit representation of spirituality in nursing education and the recognition of appropriate educational approaches in this area. Based on the findings of this study a learning framework is proposed; SOPHIE (Self-exploration through Ontological, Phenomenological, Humanistic, Ideological, and Existential expressions), to encourage self-awareness and reflexivity among nursing educators and students. SOPHIE aims to bring ontological authenticity and congruency to the forefront of nursing knowledge and practice. Conclusion: Constructing knowledge through ontological learning engagements among educators and students is essential to develop role clarity, authenticity and empowerment in understanding and addressing spiritual care needs. A multidisciplinary teaching approach integrating medical anthropology, humanistic psychology and existential phenomenology should be explored as a basis for an integrated nursing curriculum that could explore spirituality in its widest sense.

This research is an exploration of nurse education leadership, as identified and experienced by nurse teachers working in a Higher Education (HE) environment. In total 18 nurse teachers were interviewed who formed a whole population sample. The author is identified as a coworker and part of the community being researched. Semi-structured interviews and field notes were used to triangulate the data and thematic analysis was used to analyse the data. From the findings, the interviewees can be seen to have a strong professional focus and look to their own health and nursing structures to provide leadership. The acceptance of the authority of these institutions and people can be broadly located in a bureaucratic model. Their expectations of people they identified as leaders conforms to a transformational model of leadership, as they identified that leaders were people who had vision, values and influence and of particular importance was the identification of how these individuals made them feel valued. They identified themselves as problematic within the HE environment in which they work and identify being excluded from the collegiate structures and working practices of the university. The findings illuminate problems in the identification and role of nurse education leadership and their position within the university, which this author suggests are areas that need further exploration and have policy implications.

The typical picture that is conjured up when one thinks of a nurse is that of a matronly figure, in a uniform and cap, sitting at the patient’s bedside administering care. Associated with this is the traditional view held by the public, in which nurses are beholden to doctors and dependent on them for instruction, and perform a generally subservient role. However, those who have had the misfortune to require treatment more recently will testify to a far different situation, in which nurses perform a more professional and clinically autonomous role, as well as having a caring and compassionate function. In fact, the picture that exists in most clinical environments is one in which nurses are recognised as knowledgeable and capable clinicians, and independent practitioners in their own right, rather than obedient medical handmaidens. The delivery of modern healthcare has also changed beyond recognition, with interventions that were once considered to be the domain of hospital practitioners now provided in a more liberated community-based system. Within this structure, the role of healthcare professionals has similarly been transformed, such that the ‘power’ has shifted away from doctors and towards non-medical clinicians. This has, in turn, resulted in non-medical practitioners, most notably nurses, having more authority, autonomy and responsibility for clinical decision-making, rendering them more equal in the clinical hierarchy and more evenly aligned as professionals. This thesis explores the range of traditional medical activities that are now performed by nurses who have expanded their practice in order to accommodate the additional responsibilities that this 'power' affords. In particular, it looks at those nurses who have advanced their practice such it constitutes a new clinical role and, in some cases, act as medical substitutes. With the further devolution of clinical tasks inevitable, and the creation of more clinical roles likely, this thesis looks at the regulatory framework that underpins advanced nursing practice. In particular, it questions whether the existing framework provides the regulatory safeguards that are required to ensure patient and public protection and asks whether an alternative approach, such as that which is provided by another professional regulator, may be more appropriate. In concluding, this thesis will assert that a compelling case for the statutory regulation of advanced nursing practice can be made, and will suggest a number of options regarding how this regulatory solution can be achieved.

Qualified nurses require equitable access to continuing professional education (CPE) that is responsive to the needs of learners, employers and most importantly clients. There is scant attention paid to the CPE custom of community nurses, with research in the experience of island-based nurses mainly limited to the Mediterranean and under-developed islands, or of nurses working in the Scottish Isles. The community nurses in question are employed by a charity working outside the National Health Service (NHS), based on an island with a unique model of healthcare that is more medicalised and institutionalised than the United Kingdom NHS. Semi-structured, one-to-one interviews were conducted with sixteen community nurses, and two focus groups undertaken, one with nurse managers and the other with qualified nurses. Interview data were analysed using Interpretative Phenomenological Analysis, a method new to education research, and not yet recorded in relation to nurse education. Findings indicated an ageing workforce, with ageism hindering access to CPE. Geographical isolation coupled with a lack of access to tertiary education dictated CPE to fulfil professional development. Charitable status and limited CPE funding resulted in a third of nurses applying for sponsorship via local or national agencies, this was not found elsewhere in the current literature. This research contributes to the knowledge relating to nurse CPE, confirming the transferability of existing literature relating to geographical remoteness, barriers and outcomes of formal study to community nurses. It advances the current knowledge base with regard to small island infrastructure effecting access to CPE, funding formal education for nurses working outside the NHS, and silo working within the community setting. Further research is required to explore the experience of community nurses under the age of 30 years not represented within this study, who will be the future workforce when older nurses retire. These findings are of particular significance to the Jersey Health and Social Services Department who are currently redesigning the future health and social care system on the island based on a community model, nurse educators, the charity and its qualified nurse employees, and finally the island population.

Regular breastfeeding surveillance is essential to determine to what extent national breastfeeding targets are being met and how breastfeeding practices change over time. There have been irregular infant feeding studies or national surveys carried out in Kuwait so it is difficult to assess secular trends in breastfeeding practices. The objective of the Kuwait Infant Feeding Study (KIFS) was to identify the incidence and prevalence of breastfeeding up to 26 weeks postpartum among a population of women living in Kuwait and to identify the factors associated with the initiation and duration of breastfeeding. A sample of 373 women recruited shortly after delivery from four hospitals in Kuwait completed a structured, interviewer-administered questionnaire and follow-up telephone interview at 6, 12, 18 and 26 weeks postpartum. Multivariate logistic regression analysis was used to identify those factors independently associated with the initiation of breastfeeding and survival analysis was used to examine the duration of breastfeeding. In total, 92.5% of mothers initiated breastfeeding and at discharge from hospital the majority of mothers were partially breastfeeding (55%), with only 30% of mothers fully breastfeeding. Prelacteal feeding was the norm (81.8%) and less than 1 in 5 infants (18.2%) received colostrum as their first feed. Only 10.5% of infants had been exclusively breastfed prior to hospital discharge, the remainder of breastfed infants having received either prelacteal or supplementary infant formula feeds at some time during their hospital stay. At six months of age, 39% of mothers were still breastfeeding but none of the women were fully or exclusively breastfeeding. The median duration of any breastfeeding duration was 13.9 weeks. 2 Breastfeeding at discharge from hospital was independently positively associated with paternal support for breastfeeding and negatively associated with delivery by caesarean section and with the infant having spent time in the Special Care Nursery. Mothers originally from other Arab countries were more likely to initiate breastfeeding in hospital than Kuwaiti mothers. Women whose husbands worked in sales or clerical occupations and Kuwaiti national mothers were at higher risk of early breastfeeding termination. Women whose husband or own mother preferred breastfeeding, breastfed for longer than those women whose husbands or mothers preferred formula feeding or were ambivalent about how they fed the infant. Hospital-related factors including time of first feeds, type of first feed, age of introducing a pacifier and feeding on demand were significantly associated with breastfeeding duration. The results of this study indicate that while breastfeeding is almost universally initiated, very few women achieve the WHO recommendations of exclusive breastfeeding to 6 months of age. The reasons for the high use of prelacteal and supplementary formula feeding warrant further investigation. Data collected in this study will contribute to the limited breastfeeding surveillance data available for Kuwait and inform future public health policy. Hospital policies and staff training are needed to promote the early initiation of breastfeeding and to discourage the unnecessary use of infant formula in hospital, in order to support the establishment of exclusive breastfeeding among mothers in Kuwait.

The arrival of lifelong learning within nursing constitutes a major conceptual shift that every qualified nurse is expected to adopt to be able to function as a Registered Nurse (RN) throughout their career. In the 1990s, lifelong learning had been appearing sporadically within nursing literature as a fait accompli, and with a seemingly general assumption that there was a shared understanding and acceptance of the concept amongst all nurses. The literature review revealed that lifelong learning is closely linked to the evolving nature of healthcare delivery in the National Health Service (NHS), and that it comprises of a number of related components. However, there was a dearth of empirical literature with regards to its application to day-to-day nursing practice at the time this study started. The study focused on examining the assumptions that seemed extant at the time and the areas that were not documented in the literature. It sought to ascertain the nature of RNs' perceptions of lifelong learning, and took into consideration the underlying philosophy, principles and practicalities of the concept. It also sought to identify both the formal structures required for effective implementation of lifelong learning as well as the day-to-day factors that might facilitate uptake and continuation of learning. Furthermore, the study endeavoured to ascertain the current and likely future impact of lifelong learning on nursing. To explore these issues, the study involved collecting, analysing and interpreting data from twenty-six individual interviews and two focus group discussions along with a comprehensive documentary analysis. The findings revealed that there are positive perceptions as well as reservations about lifelong learning amongst RNs, the latter mainly because mandatory continuous professional development (CPD) is resented by a number of nurses. This could be due to their lack of experience and apprehension related to studying in a university. The study found that structural mechanisms could be more firmly anchored and equitably available. Numerous day-to-day factors such as profession-based and personal networks tend to influence levels of engagement in formal learning. For instance, CPD in the form of workbased formal and informal learning is relatively widely utilised. Additionally, the impact of attitude change towards continuing development of own knowledge and competence yields favourable outcomes for the RN and for patient care.

The dominant political ideology emphasises the patient as a consumer and partner in health care. Correspondingly, the move towards patient-centred nursing, based on the principles of humanism and individualism, emphasise the central role patients' should play in the nurse-patient encounter. Additionally, changing social and demographic trends highlight the importance of medication as a health care issue. Thus, current health care policy and practice contexts highlight the importance of patients' participation in health care as consumers and partners and, nurses' ability to make an effective contribution to educating patients about medication as part of their role in health education and promotion. However, despite the significance of this context, little is known about the extent and manner of patient participation, or the contribution that nurses make to this important health promotion activity. Therefore the purpose of this study is to extend knowledge in this area by describing and explaining patient participation in medication interactions, as it occurs within the reality of the clinical context. In order to study patient participation in medication interactions in the reality of the clinical context, a case study approach was adopted. Three case sites were sampled and included: 1) an acute medical ward, 2) a community hospital rehabilitation unit, and 3) a community mental health service. Data collection methods employed to explore and describe patient participation in medication interactions included: non-participant observation, audio-recording of nurse-patient interactions, nurse interviews, patient interviews, reflective field notes, focus groups and documentation. The data analysis framework included the use of conversation analysis for nurse-patient interaction data and content analysis for other qualitative data. The findings indicate that patient participation can be understood at least in part by the communicative practices and choices that nurse and patients/clients make. More specifically a range of conversational strategies were employed by nurses to initiate and control conversations and by doing so inhibited patients' participation. However a comparison of findings across sites indicates that there were both differences and similarities in the extent to which nurses facilitated and inhibited patient participation. A number of influencing factors were identified that helped to explain these findings. These include: power, nurses' communicative style, knowledge, skills and experience, patients' age, acuity of illness and level of knowledge, and the organisation and philosophy of care. The findings from the study make a unique contribution to the body of knowledge in a number of ways. First, as the only study to describe patient participation in medication interactions between nurses and patients, it identifies that participation can occur at an interactional level, as well as a more practical level via, for example, the potential to self medicate and independently manage medications. Related to this, it has also contributed to the conceptual clarity and development of the concept of patient participation. This study has highlighted that patient participation may be realised and understood more fundamentally, at the level of the nurse-patient interaction, in contrast to previous research that conceptualises participation as making choices and involvement in decisionmaking. Furthermore, by the successful use of conversation analysis, this study has also advanced knowledge about potential ways to investigate patient participation at the level of nurse-patient discourse. Finally, this study provides a contribution to advancing theoretical explanations of patient participation through the construction of a framework of explanatory factors influencing patient participation. A framework for enabling participation has been developed based on the specific conclusions and principles for action drawn from the findings and from the philosophy of Freire (1972; 1983), which acknowledges an individual's potential to be empowered and assume control. The framework proposes that addressing attitudinal, interactional, relational, educational and contextual issues, might facilitate patient participation. Implications and recommendations reflect the practice and education requirements needed to implement such a framework.

Advances in treatment and prolonged survival times mean that increasingly individuals are living with advanced cancer, yet services remain disease orientated. This thesis has documented the process of undertaking a longitudinal qualitative study to explore the everydayness of living with locally advanced rectal cancer. The study has identified how this can influence individual’s day to day lives when the focus of care moves away from cure, but prior to the transition to ‘end of life’ care. The aim was to obtain data in which to situate local service development based on those aspects which were accorded primacy by the participants. This interpretive study used a longitudinal qualitative approach which was informed by phenomenology. The philosophical works of Heidegger, Merleau Ponty and Van Manen were influential in this work which involved ten participants, with locally advanced rectal cancer. Successive interviews with ten individuals were undertaken over a two year period. The 38 interviews were analysed using a combination of frameworks offered by Miles and Huberman and Saldana. Individuals during much of this time concentrated on maintaining normality in their everyday lives. The drive for stasis and focus on day to day living allowed the individual to remain in the present and distance a future which was associated with illness and annihilation. Crucial to this was the ability to self-manage. This allowed space to create a self-definition of health. Uncertainty during this time was life affirming. Avoiding those who may challenge this, was desirable for as long as possible. As illness progressed there was an inverse relationship between the ‘boundness’ of the body and the ‘boundness’ of the individual. Insights from this study raise the need for further research and exploration of alternative models of supportive care whilst focusing on the wellness of individuals and self-management within their daily lives.

This study was carried out following observation from health professionals in the paediatric intensive care community that the incidence of chylothorax development in infants and children in the United Kingdom was unknown. Furthermore, treatment strategies were based on limited international evidence from single centre, small scale, retrospective cohort studies or case series. The aim of this study was therefore to determine the size and extent of the problem by establishing the current incidence, patient profile, management strategies and discharge destination or outcome of infants and children who developed a chylothorax in the UK. Infants and children ≥ 24 weeks gestation to ≤ 16 years, who developed a chylothorax in the UK were prospectively reported through the British Paediatric Surveillance Unit (BPSU). Clinicians completed a questionnaire on the presentation, diagnosis, management and discharge destination or outcome of these children. Three further additional data sources were accessed to confirm this data. A total of 219 questionnaires were returned with 173 cases meeting the eligibility criteria for inclusion. The incidence in children in the UK was 1.4 in 100,000 (0.0014%), in infants ≤ 12 months 16 in 100,000 (0.016%) and for those developing a chylothorax following cardiac surgery it was 3.1% (3,100 in 100,000). The majority of chylothoraces were reported following cardiac surgery (65.3%). Chylothorax was most frequently confirmed by laboratory verification of triglyceride content of the pleural fluid ≥ 1.1 mmol/litre (66%). Although a variety of management strategies were employed, treatment with an intercostal pleural catheter (86.5%) and a Medium Chain Triglyceride (MCT) diet (89%) were most commonly reported. The majority of the children had a prolonged hospital stay (median 29.5 days), with a reported mortality of 12.5%. The results of this study indicate that the development of a chylothorax in infants and children in the UK is not common; although incidence is higher in children having cardiac surgery. The duration of hospital stay is lengthy and therefore the impact on the child, family and hospital resources are significant. Common management strategies exist, but the variation in these and the lack of an outcome based rationale suggest national guidance is required.

The aim of this research was to examine nurses' and health care assistants' perspectives of infection control practice on one hospital ward and use this as the basis for the development, implementation and evaluation of an education and support programme for improving practice on the ward. In Phase I of the study, nurses and health care assistants were interviewed using a semistructured interview schedule to explore their views and anxieties about infection control practice and identify their priorities for practice development. Qualitative and quantitative analysis of these data revealed that respondents' concerns related primarily to the use of Contact Precautions for patients with Clostridium difficile associated diarrhoea (CDAD) and Methicillin resistant Staphylococcus aureus (MRS A). Structured observations of practice were employed to confirm the prevalence of the issues raised in relation to this and provide an understanding of their context. The findings of Phase I informed the design of an intervention to improve practice. This involved the development of a practice guideline on Contact Precautions and the availability of practical instruction and support during its implementation. In Phase II of the study, participant observations of practice were conducted to gain an understanding of nurses' and health care assistants' behaviour and in particular, their responses to the supportive intervention. Their perceptions of its impact on their practice were ascertained in Phase III using semi-structured interviews. Qualitative analysis of these data revealed that participants experienced great difficulty understanding and implementing infection control recommendations. Factors that may help explain this include nurses' and health care assistants' knowledge and skills in infection control, their personal belief systems and self-preservation instincts. In addition, the recommendation to use Contact Precautions for patients with infectious conditions such as CDAD and MRS A may itself counteract attempts to promote the routine use of infection control precautions in clinical practice. It is suggested that in relation to infection control, there may be a need to radically re-think the ways in which health care workers are educated and supported in practice. Moreover, it is argued that until the ambivalent evidence base relating to the use of Contact Precautions is resolved, messages about infection control are likely to generate confusion amongst health care workers.