The study was conducted in two general hospitals. The aim was to describe and analyse teaching/learning situations occurring in hospital wards, and to identify the characteristics of a 'good' learning environment. Designed in two stages, the research focused on two groups - ward sisters and learners. Part I comprises an introduction, a brief statement of the system of nurse training, a review of the literature relating to nurse education since 1919, and a discussion of theory relevant to the social order in the hospital ward. Part II describes methods and results of the first stage of the research. Part III describes methods and results of the second stage. A variety of methods was used. In the first stage wards were ranked retrospectively by using perceptual data from a sample of learners, and ward sisters were intervieWed. In the second stage, observations were conducted in three pairs of high and low ranked wards from three specialities. Activity sampling provided an overview of ward organisation, and learners were interviewed about a sample of observed activities, in order to find out how they perceived their work, and to detect 'covert' as well as 'overt' teaching. Categories of teaching and learning were derived from responses. Teaching and learning varied between wards. The results showed that activities that were perceived as being important for education were technical rather than basic. More teaching took place during technical activities. Sisters varied in the way they fulfilled their teaching and management roles. It is argued that a traditional model of nursing, dominated by hierarchy and routine, inhibits learning. The ideal environment is anti-hierarchical, and key characteristics are teamwork, negotiation and good communication. There is a team of teachers, trained nurses are available and approachable ani [sic] the sister makes a conscious effort to make teaching a reality.

Service users expect to be cared for by a nurse who is both competent and professional, a particularly pertinent point following the Francis and Keogh reports (DH 2013a, DH 2013b). Nursing students’ experience of education in practice strongly shapes their behaviour and knowledge but the ways in which this influences development of their professionalism is not yet fully understood. This study explored nursing students’ lived experience of role modelling aiming to understand the impact on their development as professional practitioners. In June 2013 twelve student nurses (4 first years, 4 second years, 4 third years) participated in in-depth interviews which were non-structured to allow exploration of the phenomenon that were most important to the participant. Using Interpretive Phenomenological Analysis, the information gathered from participants underwent several stages of thematic analysis. The influence of peers and service users on students’ professional development expands upon previously reported research. This is directly related to how students perceive their role model status and although not generalizable participants in this study found that reflecting on experiences with peers and observing the reaction by service users to care delivery had a positive influence on their professional development. Other principal findings include the importance to students of feeling valued as part of the team within their clinical placements and the potentially deleterious impact on students working with nurses who are displaying signs of burnout. Consequent to these findings, it would appear important for student nurse education to include acknowledgement of how clinical nurse observed behaviour may influence student development, facilitation of peer-to-peer interaction as appropriate to the clinical situation and the potential impact of fostering a ‘personal yet professional’ relationship with the student. A number of other issues are also identified. Given the potential influence of peers in enhancing students’ education, one way of optimising the effect of this novel finding could be to include a formal peer to peer mentoring system across all three years of a pre-registration programme. The findings indicate a limited awareness of the potential influence of academic staff as professional role models. This is a possible area for development. Students should also be guided to work with a number of staff in order to ensure exposure to a variety of practice behaviours.

Purpose: The study sought to explore junior nurses’ experiences of providing care within intensive care units (ICUs) where there is a high level of technology. Research Question The research question that guided the study was: What is the experience of junior ICU nurses caring in a technological environment? Background: Nursing practice is interwoven with technology, but there is limited understanding of the caring experience of the junior ICU nurse within a technological environment and how it impacts on the care provided to patients. Method: This study is underpinned by Heideggerian phenomenology using in-depth qualitative interviews. A purposeful sample of 20 junior Irish ICU nurses were interviewed. Data were analysed through the identification of codes, categories and themes. Findings: Three main themes emerged; ‘challenging environment’, ‘knowing and caring in the technological environment’ and ‘mastering technology’. The theme ‘challenging environment’ identified how nurses struggled to cope with the stress engendered by technological caring; they were concerned about their competence and about patient safety. They felt more comfortable when drawing on pre-existing caring skills. ‘Knowing and caring in the technological environment’ demonstrated the interrelationship of expressive caring with knowing the patient’s bodily responses; the latter an aspect that came to the fore in the current study. ‘Mastering technology’ identified competence as a maturation process in which nurses moved between being competent and being a novice depending on the type of technology and the nature of the caring event. This process required support from the multidisciplinary team. Conclusion: Junior nurses’ experiences identified the stressful and challenging nature of intensive care nursing, the need to balance expressive caring with caring for the patient’s bodily responses, and the importance of developing competence within a supportive team environment to ensure patient safety.

This study explores the nature of feeding partnerships between patients with late stage dementia and nursing staff. Twelve video dyads, consisting of four female patients and three members of their nursing team, were recorded during feeding. All twelve videos were made during the midday meal, within the normal nursing environment of the continuing care ward of a psychogeriatric unit. The videos were transcribed using an adapted conversation analysis technique. A number of small scale studies were carried out on the data. A correlation was found between the amount and type of speech used by the members of staff and the amount of food successfully fed to the patients. Demarcation of feeding was lost when there were high levels of speech, suggesting that staff members' communication should be task related so as to enable feeding cues to be detected. The findings were interpreted against a summary model which was then reconfigured into three stages. The roles of the members of nursing staff and the speech and language therapist were conceptualised and three key components of intervention during feeding portrayed. The model emphasises the staff-patient partnership and the direct and indirect influence the speech and language therapist exerts on this. Suggestions are made for further exploration and future research including communication and feeding profiles, analysis of different demarcation processes and the development of a demarcation hierarchy. Such an intervention would relate equally to other clinical areas such as neurology and learning disabilities. A number of factors were identified which challenge current speech and language therapy practice, including the link between interaction and successful feeding. It is advocated that dysphagia and communication therapies should be placed on opposing ends of a continuum rather than being viewed as separate constituents to speech and language therapy intervention. By proposing such a continuum it is possible to see how therapy can be targeted at the specific, task related interaction that is necessary for successful feeding.

Assessment tools have been shown to increase the accuracy of professionals' assessment of patients (Heaven and Maguire 1997; Sollner et al 2001; Horton 2002; Hill et al 2003; Farrell et al 2005). Whilst structured assessment of patients with advanced cancer is recommended to enhance patients' experiences of illness and treatment and improve service provision to meet their needs NICE 2004, p24), little is known about the actual practice of using structured assessment tools. There is limited evidence that nurses have the skills required to use assessment tools. Evidence also suggests that nurses may be ill prepared and inadequately supported to deal with the consequences of more comprehensive assessment of patient need. This case study used realist evaluation to identify the impact of introducing a quality of life assessment tool in two outpatient chemotherapy units. Qualitative methods of non-participant observation, audio-recording, and individual interviews were used. 38 patients attending for palliative treatments and 10 nurses were recruited; 6 nurses completed all stages of the study. Data was collected in two phases with an interim period of training in between. In Phase 1, nurses assessed patients as usual. In Phase 2 the assessment tool was used. The nurse-patient assessment interaction was observed and tape-recorded. Interpretive interviews were conducted with nurses and patients to ascertain their perspectives of the assessment. Consistent with realist evaluation, data were analysed thematically to test and refine context-mechanism-outcome configurations. Social organisation as an underlying causal mechanism provided an explanatory framework for data analysis. Findings reveal that, prior to the introduction of the assessment tool, nurses' assessments were brief and treatment-related. After the introduction of the tool, assessments were patient-led, and focused on patients' experiences. Whilst patients valued this shift in focus, results demonstrate that the assessments were time-consuming and did not necessarily prompt appropriate multidisciplinary team referrals. The use of the tool was problematic for nurses, exposing them to emotionally challenging issues, and revealed gaps in their cancer and palliative care knowledge. These findings have been underplayed in recent policy and assessment guidance. Recommendations for practice, training and future research are made which may help to ensure that guidance is successfully rolled out in the future.

The ethics literature to date has suffered from an inadequate empirical base on which to support discussion about practice, policy and education. Research in the area of ethical decision-making has been inconclusive because of unclear conceptualisations of moral problems, and different methods to investigate the extent to which nurses are confronted with them. In particular, the contextual influences on the formation of moral conflicts and nurses' responses to them have not been explored. In cancer care, there is anecdotal evidence that such influences have a powerful effect on the interaction between individual nurses and perceived moral problems. The study aims to redress previous inadequacies by exploring individual nurses' engagement with perceived moral problems as they occur on an acute cancer unit. The surrounding influences and effects on patient care are studied as part of a fieldwork analysis involving 18 months of participant observation. The researcher worked alongside individual nurses in order to deepen understanding of their perception of moral conflicts. Findings involve the central concern that ethical decisions are not made, and that this can, in part, be attributed to nurses' evident pattern of emotional distancing. The function of emotion in enabling moral engagement is a central argument of this thesis. The lack of a credible ethical language in practice and the effects of hierarchical decision-making are also explored. Against a backdrop of the frequently mismanaged border between acute and palliative care, these issues appear to combine to leave patients and their relatives unsupported as death approaches. By studying ethical decision-making in the context of its application, this study can reliably suggest ways forward in practice. The implications are far-reaching and offer recommendations which improve on those contained in recent policy literature. They will be of direct relevance to those involved in pre- and post registration, and to those responsible for acute cancer services in the UK.

At the inception of this research study the intent was to inform the debate regarding advanced nursing practice in adult critical care, in the United Kingdom. Argument within the nursing profession was vociferous concerning the nature of advanced nursing practice and to achieve some insight into the conundrum the following research question was posed, 'What is 'advanced' about advanced nursing practice in adult critical care? To pursue the research question in greater depth three aims were stated. These reflected a desire to explore the development and activity of advanced practice nurses in adult critical care; to gain a perspective of the processes involved in their socialisation and to develop a model which would reflect these elements. The research utilised grounded theory methods, within the constructivist paradigm. The purpose of this was to reflect a relativist ontology in which reality was the subject of joint interpretation and a subjectivist epistemology where the researcher and participant co-created an understanding of the phenomenon of advanced nursing practice in adult critical care, within a naturalistic context. The methodological procedures led to the construction of the substantive theory, Legitimate Influence: the key to advanced nursing practice in adult critical care. This represents a unique contribution to the extant body of nursing knowledge associated with advanced nursing practice. The central elements comprised a focus on enhanced patient stay and improved patient outcome, the development and maintenance of credibility, underpinned by an ability to engage in advanced clinical nursing practice and the development and dissemination of knowledge. The ubiquitous nature of power between, and within, professional groups was also evident in the constraints placed upon the exercise of Legitimate Influence. Participants were also able to articulate the difference between expert and advanced clinical nursing practice; critical care practice within the domain of medicine and nursing and the focus of future patient orientated nursing research. Emphasis was also placed on the importance restorative care, and the need to balance this with the exigencies of cure. The study concludes with recommendations for practice, research and policy.

The continuing care for older people is an important but often overlooked area of health care. This thesis is concerned with how care staff work with residents and their relatives in an NHS continuing care ward. It focuses on the care staff's perceptions and responses to the losses experienced by the residents and their families in their care. The research is rooted in a work based education project and the theme of loss was chosen by the participating care staff who felt it was central to their work. They coined the phrase "living bereavement" meaning the complex responses and grief reactions of those experiencing and bearing witness to the multiple losses endured in continuing care environments. The literature review suggested that the body of knowledge related to loss in continuing care is fragmented and the research aimed to explore the relationship between some of the fragmented issues. For example, by blending social and psychological methods it was possible to research the interaction between the cultural and emotional aspects of loss in continuing care. Psychoanalytical formed data collection and analysis strategies were built into the methods so that formulations could be made about the role of emotions and psychological defenses in shaping the customs and practices on the ward. A key message from the thesis is that there is an intense emotional demand in care work related to loss and grief in continuing care environments. This demand consists of the care staff's own feelings as well as their experience of other people's emotional responses. I propose that care staff used psychological defenses to avoid or gloss over aspects of the emotional demand that stirred up unbearable emotions and feelings that are usually considered unacceptable, particularly for people in care work. Social systems in the organisation of work supported the psychological defenses and prevented any changes in working with emotions becoming custom and practice in the everyday work. The study makes its unique contribution by articulating the nature of the emotional demand, psychological defenses and social systems that are related to having close contact with very dependent older people living and dying in continuing care environments. The thesis concludes by making specific recommendations about integrating the emotion work related to living bereavement for the participants in the study. Broader considerations are also suggested or similar continuing care environments such as care homes.

This thesis looks at the concept of involvement as it applies to older patients and their informal carers in the assessment of their own continuing care needs. In particular it is concerned with the nurse's role within the multidisciplinary team in facilitating the involvement of patients and informal carers in this process. The study was conducted in a district general hospital in London. Patient involvement in continuing care assessments was explored by following the care of 20 individual patients and their informal carers throughout their hospital stay, and after discharge in the community. Observations of key decision making activities in respect of these patients were contrasted with interviews with multidisciplinary staff who had been involved in their care, to provide insights into assessment practice. Interviews with patients and informal carers gave an indicator of how involved they felt in their own assessments. In addition, interviews with 32 multidisciplinary staff provided more general data on professionals' perceptions of their own roles with regard to involving patients in assessments. Analysis of the data revealed nurses were not being seen to be contributing to the assessment of patients' continuing care needs. Nurses' marginal position in continuing care assessments meant that it was particularly difficult for them to facilitate the involvement of patients and informal carers. What makes these findings all the more remarkable is the fact that nurses' continual presence on the ward was almost universally seen by the multidisciplinary team as offering them unrivalled opportunities to build a rapport with patients and thereby develop better understandings of their needs. Furthermore findings suggest that continuing care assessments and patient and informal carer involvement in this process may be affected by strategic and practice issues, as well as factors relating to patients and informal carers themselves. One explanation for these findings may be offered by Nolan et al.'s (2002) 'senses' framework. The application of the framework to the data suggests that a lack of attention to, 'the fundamentals of care' may affect professional practice. In particular, applying the framework to this multidisciplinary context suggests that a lack of these 'fundamentals of care' in one discipline may also affect the practice of other members of the multidisciplinary team. Moreover, the findings indicate that the framework may be incomplete and that it may require modification by the addition of a 'sense of expertise'. It is intended that generalizations may be made at a theoretical level from this case study.

Changes to the work of registered nurses (RNs) has generated increasing concern about the ways in which HCAs are used and the basis for the division of nursing work tasks and roles. The theoretical and empirical foundations upon which these divisions lie are often weak. Empirical data are often lacking, or of sufficiently poor quality to be questioned. This thesis seeks to understand the division of work between HCAs and RNs in adult general care in one acute NHS hospital. The thesis makes use of an interactionist perspective to frame the study's examination of the micro-social processes surrounding the daily negotiation of HCAs' work. In doing so, connections are made to the wider (macro) processes that influence nursing work. An in-depth case study approach using documents, survey, interviews, focus groups and participant observation was used to collect data on the demographic and biographic characteristics of HCAs; their perceptions of their work; the nature of observed work; the ways in which their work is supervised; their interactions with other nurses; and RNs' perspectives of HCA work. National, professional and organisation policy expectations emphasise the HCA role as one of assisting RNs under their supervision. This study reveals significant deviation from these policy goals. The workplace arena - and the negotiations that take place in it — actively shapes HCAs' work and yet policy makers often appear to disregard this characteristic. Differing amounts of power associated with the occupational groups in hospitals influence the nature and outcome of work-related negotiations at the organisational level - the results of these negotiations are variable, and lead to dynamic patterns of use, non-use and misuse of the HCA resource. These patterns led to some unintended outcomes: a resentful workforce, the creation of gaps in the application of nursing care, and traditional quality assurance mechanisms left wanting.