Learning can be explicit or implicit. Explicit learning takes place intentionally, in the presence of factual task-relevant knowledge; whereas implicit learning takes place unintentionally, without concurrent acquisition of knowledge about task performance. The relative benefits of implicit learning have been well investigated within healthy populations. Research consistently demonstrates that skills learnt implicitly are more likely to be retained, and are more robust under secondary task load. However, study protocols tend to involve laboratory based activities, which do not take into account the complexities of motor learning in natural settings. Direct transferability of the findings to stroke rehabilitation is therefore questionable. Two factors in explicit and implicit learning are the concepts of attentional capacity and attentional focus. Attentional capacity refers to the ability to attend to and process incoming information, whereas attentional focus refers to the location of attention in relation to specific aspects of the task being performed. Theories propose that focussing on specific movements (internal focus) may actually constrain or interfere with automatic control processes that would normally regulate movement, whereas if attention is focussed towards the movement effect (external focus) the motor system is able to more naturally self-organize, resulting in more effective performance, and learning. An internal focus of attention is therefore allied to explicit learning; whilst an external focus of attention is allied to implicit learning. This research aimed to improve understanding of explicit and implicit learning within early gait rehabilitation post stroke; primarily through the development and testing of explicit and implicit models of learning interventions. It has comprised three phases; a review of the literature; an observational study to gain insight into current practice; and a feasibility study to test the ability of therapists to deliver interventions with a bias towards either an explicit or implicit approach. Therapists were found to favour the use of explicit techniques; internally focussed instructions and feedback statements were used in high quantities. Practice therefore appeared to be at odds with current evidence; albeit primarily from healthy populations. Guidance for the delivery of explicit and implicit learning models in clinical practice was developed, and then tested in a feasibility study. Therapists demonstrated the ability to change their practice to bias either explicit or implicit learning; both approaches were found to be acceptable to patients and therapists. Recommendations are made on the content and evaluation of explicit and implicit learning models in future research, and specifically, in a Phase II pilot study.

The ability to learn and work in a multidisciplinary team is crucial to the delivery of healthcare that is ‘fit for purpose’ in the twenty-first century. Consequently, interprofessional education (IPE) is a mandatory requirement for pre-registration training in health and social care. However, the evidence base for the effectiveness of such programmes remains limited. This evaluative study aims to explore the potential influence of IPE at pre-registration level, using podiatry as an exemplar. In Phase One, key informant interviews were held with IPE curriculum developers from higher education institutions (HEIs) (n=8) in the United Kingdom. Verbatim transcripts of these interviews were analysed using elements of grounded theory. In Phase Two, using the qualitative results as the anchor, a survey was constructed and administered to pre-registration health and social work students in a number of parallel IPE initiatives (Sample 1: n=1151; Sample 2: n=1060), involving 6 and 5 HEIs respectively. The findings of the key informant interviews and SPSS survey analysis were subsequently combined to inform the results of the research. The findings revealed an absence of educational theory underpinning the IPE curriculum development process. In addition there were issues concerning institutional commitment to IPE, attitudes towards IPE, and inconsistencies in the approach to curriculum delivery, all of which militated against successful implementation. The results illuminated that students learn about other health and social care professions that are represented in their IPE group. An appropriate time to introduce IPE into pre-registration programmes was found to be the latter part of the academic year for students studying first year modules. Students’ readiness for interprofessional learning was found to be enhanced if they were inducted to a coherent IPE initiative with consistent approaches to learning, teaching, assessment and evaluation across programmes. However, attitude differences between professional groups emerged where students with a strong sense of professional identity and roles were less ready to engage in interprofessional learning. This study indicates that the current method of implementing IPE in pre-registration health and social care programmes is less than ideal. The development and delivery of the IPE curriculum appears to be flawed. Explanations for the findings are explored and the implications for practice and future research are considered.

Objective The aim of this study was to examine the effects of selected routine nursing interventions - endotracheal suctioning and manual ventilation (ETSMV), log-rolling, eye care, mouth care and washing - on the intracranial pressure (ICP) in children with traumatic brain injury. Design Prospective observational study over three years. Setting Single tertiary paediatric intensive care unit in the North West of England. Patients Twenty five children with moderate to severe closed traumatic brain injury and intraparenchymal intracranial pressure monitoring in intensive care (2 -17 years of age). Interventions Routine nursing care interventions. Measurements and main results ICP measured one minute before the procedure, at the maximal value during the procedure and five minutes after the procedure was recorded for the purpose of this study. Time to recovery was also recorded, in minutes. A total of 25 measurements (the first one in each child) in the first 36 hours of the child's PICU admission were analysed. Both ETSMV and log-rolling were associated with clinically and statistically significant changes in ICP from baseline to maximal ICP (p=0.005) and maximal to 5-minute post ICP (p=0.001) for ETSMV and (p < 0.001) baseline to maximal ICP and (p=0.002) for maximal to post-procedure ICP for log-rolling. During ETSMV and logrolling 70% of children exceeded the 20mmHg clinical treatment threshold during the interventions. During both ETSMV and log-rolling children with higher baseline ICPs ( > 15mmHg) showed higher maximal ICPs (but not ICP rise), suggesting a linear relationship between baseline and maximal ICP, although this was more pronounced during turning. One third of the children had not returned to their baseline ICP by 5 minutes after ETSMV, compared with 60% children after log-rolling. Neither eye care nor mouth care showed any clinically significant effects on ICP in these children, suggesting these procedures are not noxious and are tolerated very well. However, there was only a small number of washing episodes reported in this study therefore the observations are not conclusive. Conclusions Endotracheal suctioning and log-rolling in moderate to severe traumatic brain injured children can cause significant intracranial instability and should only be performed as required and with careful planning and execution. Eye and mouth care and washing appear to be well tolerated interventions and could be performed when necessary.

Background: Sedation withdrawal is one of the terms used to describe the behavioural response to stopping or reducing sedative drugs in physically dependent patients. Withdrawal behaviours differ according to the drug involved and may be unpleasant and interfere with recovery. Recognition of sedation withdrawal is challenging due to differences in patient presentation and may be further complicated by the patient’s condition and concomitant drug therapy. Overall Aim of the full thesis: To improve the accuracy of sedation withdrawal assessment in critically ill children. Objectives and Methods: A mixed methods interactive approach comprising six studies. Study 1 evaluates the psychometric properties of the Sedation Withdrawal Score, Studies 2 and 3 examine the complexities/challenges of withdrawal assessment by critiquing existing tool validation studies, A further three studies examine the nurse and parent perspectives of sedation withdrawal assessment in critically ill children. Study 4 investigates how nurses use a sedation withdrawal tool, Studies 5 and 6 investigate what behavioural signs parents recognise and ascertain parents’ willingness to participate in withdrawal assessments. Key findings: Nurses found withdrawal behaviours difficult to interpret in critically ill children and there were differences in how these behaviours were construed. Parents identified a broader range of behaviours than included in existing tools. Most parents were eager to participate in the assessment. The elusive theoretical basis for the existing approach to withdrawal assessment may account for the lack of a standardisation and poor accuracy of the current tools. A model of the causal relationship between dependence and withdrawal is proposed. Recommendations: The model identifies the diagnostic criteria upon which a definition for Pediatric Withdrawal Syndrome may be based. These criteria also provide a novel framework for withdrawal assessment. Focussing on the shared diagnostic criteria and including the parent perspective of the child’s behaviours may aid the assessment and support decision-making.

This thesis looked inside the black box of stroke care, so called because its contents are not clearly defined. This case study of success illustrated how a new inpatient stroke unit (SU) was created in an inner London teaching hospital, transforming treatment for patients with stroke. Whilst it is known that good stroke care results in improved patient outcomes, it is not fully understood how or why. As stroke is the second major cause of death in adults worldwide, and a leading cause of adult disability in the UK, it is essential more is known about how evidence translates into practical knowledge for use in mainstream practice. This action research study, through the systematic documentation and evaluation of the processes and outcomes, has unpacked and illuminated factors that enabled development of success, and provides the first empirical account of its kind. This study adds to the knowledge of knowing how. A variety of qualitative and quantitative methods were used to generate data between January 2001 and November 2002. Findings were analysed using Immersion I Crystallization and descriptive statistics. When the black box of stroke unit care was opened, four key interrelated themes emerged from the process findings: building a multidisciplinary stroke team; developing practice based knowledge and skills in stroke; valuing the central role of the nurse in stroke care and creating an organisational climate for supporting improvement. Analyses of findings suggest the creation of excellence in stroke care was linked to the development of a Community of Practice (CoP), which combines three elements; domain, community and practice, into a conceptual framework of learning that fundamentally places the acquisition of knowledge into a social process of learning. Whilst improvement initiatives have recently been linked in the literature to CoPs, no guidance is available on how this should be done. This thesis makes an original contribution to the body of knowledge by providing the first empirical evidence of not only on how a CoP was created, but shows how it developed into a functional multidisciplinary CoP, a concept identified in the literature as difficult to accomplish. In concluding, issues related to practice, research, education and policy are raised for future considerations.

Breast cancer is a major health challenge. It is also is a high profile disease with extraordinary media attention that places an immense burden on women, families, children and health resources. Over the last two decades the way in which women experience breast cancer has undergone significant changes. The implementation of the National Health Service Breast Screening Programme, development of specialist multidisciplinary teams, and greater involvement of women in decision making surrounding treatment choice are just some of these changes. A discrete clinical nurse specialism has developed to provide support and information to women undergoing treatment and care for breast cancer. This multi-method two staged study explored the work of breast care nurses supporting women with breast cancer. The particular focus was on the body image and sexuality dimensions of the breast cancer experience. Firstly, a postal survey using modified versions of the Sex Knowledge and Attitude Test (Lief and Reed 1972) and the Williams-Wilson Sexuality Survey instrument (Wilson and Williams 1989) was undertaken and completed by breast care nurses (n=100) across England. Secondly, adopting an interpretative perspective, breast care nurses (n=29), recruited via the earlier survey participated in focused conversational interviews. In addition a secondary analysis of two focus group interviews with women breast cancer patients (n=14), and a further two individual interviews with lesbian women were undertaken. The audio taped data was analysed using a thematic approach assisted by ATLAS.ti 4.1 qualitative software (Muhr 1996). Three major themes: the delivery of breast cancer care, knowing women, and the territory of breast care nursing were developed. The theme of knowing women was connected with three sub themes titled: authenticity and domesticity, moral journeys, and the (in)visibility of lesbian women. The thematic analysis presents a critical account of contemporary breast care nursing in the endeavour of "being there for women".

The study is about the experience of Arab University students whose main subjects are taught in English. It investigates and discusses many English language problems in the Kingdom of Saudi Arabia in teaching, learning and studying medicine, pure science and technical English. In general, Arab learners of the English language encounter problems in the four skills of the English language, in speaking, writing, reading and listening. They also show weaknesses in many aspects of the English language such as vocabulary, grammar, pronunciation, spelling, morphology and syntax. The question is how these language difficulties affect their studies in medicine. The initial hypothesis was that all depended on the students’ facility in English, but this turned out not to be the case. The research started with the analysis of students’ written replies to questions. This was followed by the development of a questionnaire distributed to 736 medical students. This explored various factors in relation to their success in exams to find out which factors might be significant. There were few correlations between success in medical exams and previous encounters with the English language. The one correlation between the test results and the questionnaire findings was not the uses of and familiarity with English but the parents’ background. The research therefore went on to explore, through interviews, and analysis of written statements, the students’ attitudes towards the teaching of medicine in relation to the use of the English language. It was found that the hypothesis of the importance of English as a prerequisite for success was not borne out. What was discovered was the students’ pragmatic attitude towards their study and that what they thought they needed as medical practitioners depended on a kind of secondary technical vocabulary. The research discusses some of the effects of learning and teaching theories and their relationship to the process of the education system. Whilst social constructivism is held to be the ideal one to apply to the learning process, this research demonstrated that behaviorism and rote learning still dominated the experience of the students in their learning of medicine. Despite their continued commitment to the ideals of learning English, the students took a pragmatic approach to their studies, which consisted of a mixture of Arabic and English medical vocabulary.

This action research project aimed to develop inter-professional peer clinical supervision involving nurses and allied health professionals within a community health care organization. The literature revealed limited evidence regarding the development of supervisory relationships in peer group supervision and a deficiency of insider reports of interprofessional peer supervision interactions. Preparedness of practitioners and lack of protected time remain as barriers to sustainable clinical supervision. An inter-professional peer clinical supervision group (IPPCSG) was constituted via a four phase action research process. A qualitative approach was employed using a single case study design. The involvement of participants as co-inquirers reflected the participatory nature of action research. All sessions were audio-recorded and fully transcribed with data analysed using Template Analysis. A theoretical framework was developed to support the interpretation of the findings drawing on concepts of democracy and power. This action research study revealed the part played by structure and rules in securing a safe supervision space, with the incorporation of democratic principles being crucial in equalising power relationships. The study illuminates how trust developed and how supervisory relationships matured and provides detail of the transitions between functional peer supervision group roles. Valuable insights have been gained into how challenge and support are balanced when exploring decision-making and risk. The findings suggest that the different professional identities and perspectives within this group did not impinge on the development of effective supervisory transactions. Substantial common ground was revealed regarding issues brought to supervision, professional beliefs, values and experiences. The analysis suggests that processing work-generated emotion should be a core component of supervision. Learning about each other’s practice and learning how to ‘do’ clinical supervision were identified as important outcomes by co-inquirers. The analysis and interpretation of these data produced the Triple Diamond Model of Interprofessional Peer Group Supervision which may resonate with other practitioners and conveners of group clinical supervision. The evaluation of this action research study identified valuable outcomes for co-inquirers in regard to capacity building and personal development and to a lesser extent for the wider organization in contributing to the development of clinical supervision. The IPPCSG has been maintained since the conclusion of the study.

The main aim of this study was to explore student nurses and lecturers’ perceptions of directed study time (DST) within an undergraduate nursing curriculum. Previous research pertaining to the phenomenon has predominantly focused on how students approached learning, and the pedagogical preferences of lecturers and students. A wealth of quantitative literature demonstrates attempts to measure students’ preparation for self directed learning (SDL). Whilst a substantial amount of research has identified that students are unprepared to study independently and direct their own learning; no research has explored the underlying reasons behind this, nor has any research explored the perceptions of DST within undergraduate nursing curricula. A hermeneutic phenomenological approach was used to understand and interpret the participants’ perceptions of DST. The research was undertaken in two phases. In Phase One three focus group interviews were undertaken with student nurses on an undergraduate adult branch nursing course at an English university. In Phase Two, individual semi-structured interviews were carried out with nurse academics from the same university. Template Analysis was used to analyse the data and to determine key themes. Significant findings revealed that both groups perceived DST to be owned by student nurses, who controlled DST. The identities of the groups was not reflective of their roles and resulted in a lack of belonging to the university; this led to limited levels of engagement by both parties with academic activities. Many student nurses did not engage with SDL during DST and the majority of lecturers did not value academia. The culture was influenced by the ‘hidden curriculum’ within which nurse lecturers lacked authority and relied on traditional pedagogical methods to regain a sense of control. The participants also described how some students’ mentors did not value academia and did not always recognise the importance of linking theory to practice. The implications of this research study emphasise the need for a multi-faceted approach to promote the value and importance of academia within the nursing profession.

Introduction: Spirituality is a concept central to healthcare practice, and in particular to occupational therapy. As a profession, influenced from early Judeo-Christian religious beginnings, occupational therapy has retained yet translated this as a commitment to holistic, person-centred practice. Occupational therapy holds the uniqueness of the individual, and meaningful and purposeful expressions of health and well-being through occupation, as central to professional practice. Set in the context of 21st century healthcare, this thesis explored how occupational therapists (n=4) working in the English National Health Service (NHS) embedded spirituality into daily practice. Methods: Two studies were undertaken, first a structured literature review and concept analysis, applying the method outlined by Walker & Avant (2011), to conceptualise spirituality as described in occupational therapy practice. Second, a qualitative study was undertaken, underpinned by an ethnographic approach, using participant-as-observer observation and follow up interviews to explore how occupational therapists embedded spirituality into everyday practice. Framework approach was used to guide analysis and interpret the large volume of unstructured textual data. Findings: Despite the difficulties defining spirituality occupational therapists appeared able to apply the underpinning core values and philosophy of the profession and embed spirituality in their practice. Practitioners found it more meaningful to describe spirituality in terms of how they applied the concept in, and through, practice by comprehending the values, needs and concerns of the individual as opposed to a consistent definition. Occupational therapists engaged with spirituality by concerning themselves with supporting patients experiencing vulnerability due to disruption in their health and well-being. This support was achieved by the occupational therapist uncovering the individual needs of the patient and through delivering person-centred care by explicitly addressing spirituality. The scope to embed spirituality was on occasion limited by organisational and contextual factors that restricted the potential to practice fully. Achieving organisational targets by adopting time constrained interventions was perceived as having a particularly limiting impact on embedding spirituality in practice. Conclusion: The Embedding Spirituality into Occupational Therapy (ESpiOT) model which emerged from the findings of this study is offered as a tool to guide practice, education and research into how spirituality is, and could be, embedded into occupational therapy practice.