The aim of this qualitative study was to explore couples’ experiences of living with MND (MND). Previous research has not focussed on the experiences of both people with the disease and their partners, but tended to look at each separately. In examining the experiences of both side by side and reflecting on each other, the aim of this study was to explore an overlooked aspect of the experience of living with MND and make an original type of contribution to the extant literature. Method Most previous research into MND has relied upon quantitative methods. The study used a qualitative method and collected two types of data. The longitudinal case study comprised analysis of one couple’s journal of their experiences of MND, spanning the period of one year, from the diagnosis to death of the individual with the disease. It also incorporated a narrative interview of the couple. Narrative interviews were also carried out with 12 couples. Interpretative Phenomenological Analysis was used to analyse the data. Results From the analysis utilizing Interpretative Phenomenology, themes were derived from the data. The super-ordinate themes of altered body, diminishing self, altered temporality and transcending embodiment were established, with many subordinate themes deriving from these. The study reveals that although couples experienced significant physical deterioration and emotional and social losses, they developed new understandings of themselves and each other, in relation to the abstractions time and embodiment, which enabled them to cope with living with the disease. Conclusion The study suggests that living with MND can be understood as something individuals with the disease and their partners respond to in ways that intimately link them together. The study proposes that couples may be better supported by psychological services and considers how this might occur.

Background: Interest in understanding the socialisation processes that student nurses are exposed to during clinical practice has endured and is warranted given that first year undergraduates have to adapt and develop intellectually, socially, emotionally and culturally to ensure successful transition and acculturation into higher education. In addition, when first year undergraduates are also student nurses, they must display versatility and tenacity in pursuing a professional identity often in complex, changing and reforming health care and educational environments. In the UK at present the main curricula design consists of equal parts theory and practice and undergraduate student nurses experience clinical placements much sooner than their predecessors. This transitional period has received less investigation and therefore, this study aims to redress this imbalance. Purpose: To explore the impact of initial clinical experiences on the professional socialisation of student nurses. The intention has been to allow the student nurses to ‘tell it as it is’ about their experiences of becoming a nurse, the essence of which could generate a substantive grounded theory. Setting: Two placement areas, consisting of a rural District General Hospital and a large inner city Hospital that reflect diverse socio-economic areas in the north west of England. Method: A classic grounded theory approach (Glaser 1978) was used. The sample consisted of twenty-six (26) student nurses recruited from four (4) intakes over a two year period. Diary keeping was the main data collection method and seven (7) key informants from the first two intakes volunteered to take part in an in-depth interview during the second or third year of their course. Findings: The substantive grounded theory of Finessing Incivility, explains how undergraduate student nurses respond to prevailing concerns regarding their student status, learning opportunities and a lack of professional benevolence during the initial clinical placement. In order to resolve these concerns and relocate their status back to a student from a worker, they maintain values, remain resilient and display and use finesse to broker for learning opportunities and resolve their concerns. The usefulness and originality of the theory is the conceptual explanation it offers of the psychosocial processes that student nurses engage in, and with, during practice that has not been previously noted. Limitations: Although the solicited diary accounts were requested daily, the possibility exists that they were kept less frequently, filled in retrospectively, or not at all (Hyland 1996, Bowling 2002). A larger sample would have negated potential effects of attrition. In addition, and in the absence of participant observation, the accounts are accepted as truthful, although the risk exists that the students exaggerated or distorted their accounts to demonstrate how bad they felt concerning their experiences. Discussion: The theory has yielded insight into the complexities involved in becoming a professional nurse. The theory of ‘finessing incivility’ has implications for nurse educators and other allied health professionals during practice and field exposure. Exploring the experiences of other allied health students with regard to the concepts of finessing and resilience in response to incivility and loss of student status merits further investigation as do the perceptions of mentors involved with student nurses during the initial placement.

A study to explore the experiences of Advance Care Planning amongst family caregivers of people with advanced dementia. Aim The purpose of this study was to gain an understanding of Advance Care Planning (ACP) process and experiences from the perspectives of family caregivers as proxy decision makers for a relative with advanced dementia at the end of life. Methods The study involved family caregiver experiences of Advance Care Planning within a specialist dementia unit. A qualitative approach using single cases (close family relatives) was chosen for the study. Data were recorded using semi structured interviews from a self selecting onvenience sample of twelve family relatives of residents with advanced dementia in a long term care setting. All respondents had been involved in proxy decision making relating to the care and treatment of their relative with advanced dementia. Data were analysed using content analysis. Results The family caregiver experiences of Advance Care Planning were numerous and complex. Study participants described Advance Care Planning as a distressing but necessary activity. Study participants were able to give a good explanation of what was discussed during the completion of the Advance Care Plan. This included management of pain, medical interventions and treatments and also nutrition and hydration needs. A composite case was developed and highlighted several factors that can impact upon the success or failure of Advance Care Planning discussions with family caregivers. This included: adequate education around Advance Care Planning and more information on dementia for families. Conclusions Advance Care Planning is a relevant and useful activity to undertake with family caregivers. The value of using Advance Care Planning for the family caregiver allowed the best care for their relative to ensure a dignified death within the care home setting was paramount. However the ethical burden 'to do the right thing' can contribute to the already distressed family caregivers and should therefore be supported by experienced and educated health professionals.

Background: Despite common usage of oxygen as a therapeutic intervention, audit suggests the existence of poor prescribing and administration practices. Contemporary studies and guidelines propose an influencing culture whereby oxygen is given to alleviate breathlessness and to most acute clinical presentations, with disregard for potential drawbacks; but there is no evidence supporting this claim. The problem self-perpetuates as erroneous beliefs are passed to patients, their carers and the general public. Aim: To explore healthcare professionals’ (HCPs) and patients’ perceptions of oxygen therapy. Method: Semi-structured interviews were undertaken with 28 patients and 34 HCPs (including nurses, paramedics, pharmacists and general practitioners). Self-reported beliefs and behaviours were recorded, transcribed verbatim and analysed iteratively using interpretative phenomenological analysis (IPA). Results: Three master themes were identified: oxygen as a panacea, the burden of oxygen, and antecedents to beliefs. Sub-themes under these constants differed between HCPs and patients, but fundamentally both groups viewed oxygen as an innocuous therapy with numerous benefits. Patients used oxygen for breathlessness and as an enabler; they were grateful to the oxygen and accepted it as part of the disease. HCPs used oxygen because it helps patients; it works!; it makes HCPs feel better, and also out of compassion. But oxygen is not benign and a burden is evident, for patients it makes the disease visible and carries associated costs. For HCPs there is an awareness of the dangers and the patients’ burden, which often results in clinical dilemmas and an emotional cost to caring. The study exposed patients’ potential antecedents to beliefs as faith in HCPs and past experiences; for HCPs these were entrenched culture and expectations. Patients appeared not to think about oxygen and understanding was poor. All HCPs believed they had not received enough education specific to oxygen, and an approach of DIY education prevailed. Summary: These findings suggest that a set of fixed beliefs regarding oxygen therapy exist, influenced by several impacting factors. The overwhelming perception that oxygen is a universal remedy presides, but is, at times, contradictory, when benefits are countered by adverse effects of oxygen. These adverse effects, additional to physiological dangers, included psychosocial and emotional costs. This is the first time that perceptions of oxygen therapy have been reported and will be an important contribution to knowledge, supporting strategies to raise awareness of entrenched cultures, influence future educational and research strategies, and inform policy.

Background: There were approximately 63,097 known asylum seekers in England in 2002 (Heath et aL 2003). Women asylum seekers may be more seriously affected by displacement than men, leading to increased isolation, poverty, hostility and racism (Burnett and Peel, 2001a). In England, Black African including asylum seekers and newly arrived refugees had a seven times greater chance of maternal modality than White women (CEMACH, 2004 p244). Furthermore, women from ethnic groups other than white are twice as likely to die as women in the white group. In the CEMACH report a large number of women who died spoke little English. Access to local information about asylum seekers and refugees was difficult to obtain and suggested a disorganised service provision for this group of women. Aim: It was the intention of this study to explore and synthesise the experience of midwifery care by women asylum seekers and refugees in one large maternity unit in England. Design: Longitudinal exploratory case study research utilising a series of interviews. Sample: Four women from: Afghanistan, Rwanda, Somalia and Zaire. Three women were asylum seekers and one was a refugee. One woman spoke fluent English. Setting: Liverpool Women's Hospital and the women's homes. Years: The study took place from December 2002 - July 2003. Methodology: The research was developed from a constructionist paradigm which identifies that multiple realities can exist for individuals who experience 10 a similar phenomenon. Truth within this perspective is constructed by the individual. The researcher (LB) was the main instrument of data collection. Interpretation was generated via the researcher and was verified by the women at the final interview. The underpinning foundation for this study emerged as symbolic interaction theory (Mead, cited in Morris, 1967 p43; Blumer, 1969). Methods: Following ethical approval consent was obtained with the help of professional interpreters. Exploration was facilitated by in-depth interviews at five time points throughout the antenatal and postnatal period. Photographs taken by the women themselves were used as a prompt for conversation. Analysis: The researcher's interpretation of the data identified emerging themes and categories. The process of analysis involved decontextualisation, display, data complication and re-conceptualisation (Miles and Huberman, 1994 p10). Three key themes were generated: the influence of social policy, understanding in practice and the perception of 'self. Results: Synthesis of the results suggested that social policy directly affected the lives of the women. At times, "taken for granted" communication created a barrier to understanding for the women. Stereotype was socially constructed and pervaded the care environment. The women perceived 'self as a response to social interaction. The midwife-woman relationship relied heavily on gestures and symbols and the women's descriptions are related to symbolic interaction theory. Midwives capable of understanding the subtle cues in communication may be able to negotiate negative stereotypical images generated by society. Women had little or no information around childbirth. Recommendations: Midwifery care would benefit from a deeper understanding of how the women in this study perceived 'self. An advisory post may provide the link between maternity care and broader public health issues. Midwives should engage with asylum seekers and refugees to develop partnerships in care. A collaborative partnership may assist in creating relevant information around childbirth for other asylum seekers and refugees. Innovative methods of dissemination of information related to childbirth should be facilitated by a collaborative approach with non-governmental and community organisations.

Computers have, over the past 10 to 15 years, become an integral part of many activities carried out by British community pharmacists. This thesis employs quantitative and qualitative research methods to explore the use of computers and other forms of information technology (IT) in a number of these activities. Mail questionnaires were used to estimate the level of IT use among British community pharmacists in 1989 and 1990. Comparison of the results suggests that the percentage of community pharmacists using computers and other forms of IT is increasing, and that the range of applications to which pharmacy computers are put is expanding. The use of an electronic, on-line information service, PINS, by community pharmacists was investigated using mail questionnaires. The majority of community pharmacists who subscribed to the service, and who responded to the questionnaire, claimed to use PINS less than they had expected to. In addition, most did not find it user-friendly. A computer program to aid pharmacists when responding to their patients' symptoms was investigated using interviews and direct observation. The aid was not found to help pharmacists in responding to patients' symptoms because of impracticalities involved in its operation. Use of the same computer program by members of the public without the involvement of a pharmacist was also studied. In this setting, the program was favourably accepted by the majority of those who used it. Provision of computer generated information leaflets from pharmacies was investigated using mail questionnaires and interviews. The leaflets were found to be popular with the majority of recipients interviewed. Since starting to give out the leaflets, 27 out of 55 pharmacists who responded to the questionnaire had experienced an increase in the numbers of prescriptions they dispensed. 46 had experienced an increase in the number of patient enquiries they received.

This Thesis examines the development of trained district nursing in rural Gloucestershire from the 188Os, when Elizabeth Malleson, founder of the Rural Nursing Association (RNA), moved to the area, until 1925, when the first State Registration examinations were held and a new era began for the entire nursing profession. The transition from local provision of aid by untrained women to the organised delivery of care by specially trained nurses employed by the RNA is described, and the expansion of this local charity into a national scheme is traced to its affiliation and eventual amalgamation with Queen Victoria's Jubilee Institute for Nurses (QVJI), the organisation from which the current system of district nursing has evolved. The aims and motivation of the midde- and upper-class ladies who became involved in the administration of the rural district nursing movement are considered, with particular reference to religion, politics and the opportunity to expand their lives beyond the limited role prescribed for them by the cult of domesticity. The official aims of the district nurses themselves, of curative care and preventative education, are traced, and theory and practice are then compared and contrasted. The working lives of the district nurses are described, including their duties, workload, salaries and living conditions, with additional reference to the contemporary ideologies of 'fit work for women', social isolation versus independence, and relationships with administrators and local doctors. Consideration is also given to the question of whether the service provided by those who believed that they knew what the sick poor needed was, in fact, what the poor themselves actually wanted. To this end, the educative aims of QVJI are examined in comparison with two of the most fundamental and sustaining elements of life amongst the poor, especially in isolated rural communities - neighbourliness and intergenerational support.

This thesis is the first research of its kind to examine the career journeys of leading African, African-Caribbean and Asian, male and female, nurses' careers in England, and adds substantially to our extremely limited knowledge concerning the black professional class in Britain. It examines the barriers, the career opportunities, personal motivations and cultural capital that the respondents drew upon to negotiate and deal with racialised social and professional structures from the entry gate into nursing to their current appointments as senior managers in nursing, nurse management, research or nurse education. This study has considerable policy relevance in view of the National Health Service (NHS) commitment to recruit qualified nurses from overseas to combat the nursing labour market shortages. The research was conducted in three phases over a period of six years using an oral biography / life history approach to obtain narratives from eighty-eight black respondents working and domiciled in England. It revealed that the group of black nurses who had reached senior levels had became highly qualified and had contributed to service, policy, education and research development at the local level. There is also substantial evidence of their contribution to nursing at national and international levels. The findings also reveal that respondents experienced self-reported unequal treatment at the entry gate and throughout their career. The staying power and career journeys of these respondents show that the intersection between social structures of class, 'race' / ethnicity and gender, and personal agency is important in shaping careers and is influenced by social, professional, political shifts and constraints, suggesting that how individuals negotiate and deal with racialised barriers is linked to both their 'stocks' of cultural capital and their personal motivations and determinations. This structure-agency relationship counters much of the research on 'race' and occupation which has looked primarily at racialised structural barriers to advancement.

Aim: The purpose of this study was to explore the lived experience of migrant Pakistani nurses working in the United Kingdom. Background: Pakistani educated nurses have a history of migration to Middle Eastern and developed countries, and despite severe nurse shortages the Pakistan government has no strategy to retain these professionals. Pakistan saw an unprecedented shortage of nurses during the years 2000-2007 when about 1200 nurses migrated to the United Kingdom. This nursing ‘brain drain’ has negatively impacted on the health system in Pakistan, leaving it depleted of experienced health workers. Nevertheless, what motivates Pakistani nurses to migrate, and post migration experiences of these nurses are not known. Methods: This study adopted the principles of hermeneutic phenomenology to explore the lived experience of Pakistani educated nurses working in the UK. A total of twenty one Pakistani nurses working and residing in the Northwest, Yorkshire and East Midlands of England were interviewed, including eleven females and ten male participants. In-depth face to face interviews were conducted with participants, supplemented by demographic information sheets, observations, and field notes. Analysis was carried out using van Manen’s thematic approach. Findings: Findings of the study reveal the complex nature of the ‘life world’ of participants and both dismal as well as affirmative experiences were revealed. The three major themes which emerged from the study findings were ‘Becoming a Migrant’, ‘Dissonance and Devaluation’ and ‘Outsider Identities’. The lived experience of nurses showed physical and emotional hardships in Pakistan that pushed them to leave the country and move abroad. Once migrated to the United Kingdom, these nurses started their careers in elderly care homes and found themselves devalued and deskilled. In addition, their lived experience included feelings of being isolated and alienated in the UK. Discussion: The meaning of study findings reveals the concept of ‘otherness’ as core to understanding these experiences in the socio-cultural and geo-political context of the study. The meaning of Pakistani migrant nurses’ lived experience is linked to marginalization, the politics of identity and belonging. The study is one of the first to describe the notion of ‘otherness’ as a means of understanding nurse migration, and adds to knowledge of the phenomenon of ‘otherness’ as it is lived and constructed. This study has also given voice to a small group of Pakistani migrant nurses who have otherwise been marginalised by their society, their profession and their migration to the UK.

Barriers to effective postoperative pain management mean many patients suffer needless pain. Few studies have observed nurses as they manage postoperative pain in a clinical setting; those who used observation have demonstrated the importance of context to pain management practice. This ethnographic study aimed to examine what factors influenced nurses when they made pain management decisions, and how the culture of the clinical environment impacted on pain management practice. One hundred and fifty seven hours of participant and non-participant observation, semistructured interviews with thirty-six members of staff, contemporaneous field notes, and document analysis were used to investigate the culture of pain management in one postoperative ward. Analysis identified three themes with sub themes. First, the revealing of a pain management culture, which incorporated the ward environment and processes, and a new finding of the silence of routine pain management communication. Second, nurses' decision-making responses to pain management opportunities including a new finding of a single pain management action. The final theme is nurses' expectations of patient behaviours and knowledge, including how patients should look, what they should say and know, and nurses' responses to patients who do not conform to expectations. The findings suggest culturally mediated pain management behaviours, linked to a ward culture where pain was not a priority, leading to inattention to pain management. Using Social identity theory these behaviours are presented as in-group pain management social norms; part of the culture of 'how pain management is done around here'. These pain management in-group behaviours are presented as the critical factors influencing nurses' pain management decision-making in a clinical setting. They are not targeted through traditional education and their explication may indicate pain management education should be directed more towards cultural change.