This paper describes a three-year action research project, aimed to support staff in recognising and responding to loss of personhood in a continuing care setting. The context of this study was a National Health Service (NHS) nursing home for the long term care of older people. Interventions used to support this development included the collection and sharing of residents' life histories, weekly team supervision meetings for staff, an action learning set for managers, and monthly external supervised meetings for both the action researcher and senior manager. This paper reports on the processes and outcomes of change achieved and the learning gained from working in a collaborative way with staff. Given that current policy indicates the need for person-centred care (Department of Health 2001a), this study provides a possible mechanism for putting it into practice, through a systems and psychodynamically informed approach.

This qualitative study explores the experiences of young adults with Asperger's syndrome and their parents. Using grounded theory methodology, young adults with Asperger syndrome (n=18) aged 18-35 years and parents of young adults with Asperger's syndrome (n=23) were interviewed. Participants represented twenty-five families and a total of 42 face-to-face interviews with young adults and parents were conducted. Some interviews were carried out with young adults and parent/s together, others separately. Secondary or other data sources were used in the constant comparison of interview data, this included published personal accounts and notes taken from telephone conservations, meetings and conferences. Theoretical sampling and constant comparative analysis were the processes by which a substantive theory emerged about the phenomenon not quite fitting in -a multi-dimensional concept that offers one explanation of the varying experiences of both young adults with Asperger's syndrome and their parents. The non-obvious nature of Asperger's syndrome was central to the overall experiepce of not quitefitting in for young adults and their parents. Young adults 'looked normal' and had normal levels of intelligence but they behaved in ways that seemed 'socially inept', 'socially awkward', 'inflexible', and 'lacked empathy'. They expressed 'feeling different' from others, and had difficulty identifying a sense of 'self' in relation to others. Parents also described ways in which they did not quilefit in to normal expectations of parenting an adult son or daughter. Parents did not regard themselves, nor were they recognised by others, as 'informal carers'. Furthermore their son or daughter did not perceive themselves as being 'cared for'. Nevertheless, the data revealed a considerable amount of 'caring' involved for parents, both psychological (psychological 'watching over', companionship, managing emotions) and practical (providing shelter, food, security, money). Interestingly, this unacknowledged 'caring' was often carried out without the knowledge of young adults, and was both inadvertently and deliberately 'covert' in nature. Through the process of constant comparative analysis, the phenomenon of not quite fitting in was theorised through integrating the findings with other literatures; biographical, empirical and theoretical. Through this process, a symbolic interactionist perspective, derived from the work of G. H Mead (1934) about self and society, emerged as a framework that offered a theoretical explanation for the phenomenon of not quitefitting in. 'Me study also reflects on the many ethical and practical dilemmas of undertaking research with this particular group of participants. Finally, the study has implications for practice and further research in relation to health care professionals, such as health visitors, school nurses and family doctors, who are not specialists but who may come into contact with children and adults 'living with Asperger's syndrome', often before a diagnosis has been made. In concluding the study these implications for practice are briefly outlined for the stimulation of further thought, discussion and research.

The thesis explores the application of Continuing Professional Education learning in the work place, and evaluates the factors contributing to its application to clinical practice. The research specifically reviews and assesses relevant literature and theories of adult learning and evaluation. Using existing literature, empirical research work was undertaken in three case study sites. The methodological strategies of illuminative evaluation were utilised in the study, the innovation was examined in the context of "Learning milieu" (Snyder, 1971). Observations of documentary evidence, interviews with course participants and their respective managers and pre and post course questionnaires constituted the data collection. The combination of data assisted the researcher in "illuminating" issues, significant features and problems. The research study systematically and logically investigated, unfolded and clarified issues as they arose. The study utilised a qualitative approach supported by quantitative data in order to reveal individuals' learning processes within the organisations (case study sites) and comprised of three main phases of action, which in practice were more like inter-related loops. A review of existing literature, an introductory visit to the three research sites; questionnaires, distributions and semi-structured interviews with the stake holders; and the writing of the case studies to reveal impact and application to practice. A cycle of "planning, acting, observing and reflecting" was implemented throughout. In this research study the researcher constructed and adopted a multi-dimentional integrated approach, acknowledging not only the social environment in which adults find themselves, but also the cognitive dimensions. Therefore, the study was close to its social context and the "reality" as experienced by the course participants. The researcher strived to understand programmes and situations as a whole. This holistic approach assumed that the whole is greater than the sum of its parts. It further assumed that a description and understanding of a programme's social and political context is essential for overall understanding of that programme (Patton, 1990). A number of issues were identified from the research study and recommendations made. Their adoption will be particularly valuable to those currently involved in Continuing Professional Education, Nurse Managers, Practitioners, Purchasers and Commissioners of Health Care.

Workplace violence is a serious issue in health care with international surveys revealing disproportionate involvement in certain professional groups, for example, ambulance staff, nurse and student nurses, or settings, for example, mental health and learning disability, elderly care, and A&E units. Staff training is widely advocated as the appropriate organisational response but there are relatively few published evaluations, and so much remains unknown about training effects or effectiveness. Many published studies are flawed by use of small samples, poor control of extraneous, organisational variables, absence of pre-test or follow-up data, limited range of measures, and weak statistical analysis. This study examined an existing training programme for student nurses whilst attempting to avoid the limitations identified above. The effects of training on a number of learning domains, for example, knowledge, self confidence, beliefs and attitudes, and self –assessed skills was investigated using a repeated measures, variable baseline research design, in conjunction with a model of learning. The likelihood of student nurses involvement in violent incidents, and the power/ease of use of different change evaluation methods were also investigated. Repeated administration of a purpose -designed questionnaire at four time points to three consecutive cohorts of student nurses [N=243] provided information about pre-training stability, possible changes on immediate training completion, and at three-months follow-up, after two clinical placements. Statistical analysis revealed the Unit to have generally desirable effects on learning domains that were still detectable at three-month follow-up. It also highlighted differential involvement in violent incidents based on placement type, and important differences between evaluation methods in terms of ease of use.

In 1984 the English National Board (the newly appointed controlling body for nurse education in England) invited schools of nursing to submit innovatory and progressive programmes for nurse education. Basis for selection was the capacity of the programmes to begin to address the demands for a new type of nursing practitioner. The programmes were to be aimed at providing an education that would enable the nurse of the future to adapt to the changing needs created by an increasingly dynamic nursing profession. It was proposed that the selected programmes would act as forerunners for new educational initiatives and facilitate the transition to a more clearly oriented nursing approach. The longitudinal study was designed to evaluate the effectiveness of one of the selected pilot educational programmes. It was premised on the assumption that traditional hierarchical nurse educational approaches may affect student self esteem and in consequence the ability of the qualified nurse to achieve the self confidence required for independent professional practice and self-growth. It rests on the argument that a positive self image and external locus of control allows nurses to become self assertive, confident and dynamic practitioners capable of embracing and initiating change in response to predicted continuing change in psycho-social health demands. The innovations introduced in the pilot scheme included the adoption of a humanistic, student centred, adult educational model of teaching/ learning approach that focuses on promoting self worth in its learners. This led to the study proposal that the effectiveness of the course can be evaluated by focusing on whether the educational changes eliminate the potentially destructive effects of earlier courses on nursing students by enhancing their self concept to the benefit of their self confidence in practice during supervised training and after qualifying. The study draws on the theories of the Self, on Attribution Theory. Social Learning Theory and in particular Adult Educational Theory with its focus on recognition of self-worth. It utilises an eclectic illuminative evaluation method that encompasses a balance between quantitative measurement and qualitative information. The results of measurements taken of students values and perceptions of themselves and their chosen profession on entry and at differing stages of the course. Are recorded together with further measurements undertaken by a sample of course graduates after a period of practice. Methods included the use of self designed and standardised instruments and individual and group interview techniques. The descriptive study also explores and compares the demographic characteristics, values, expectations and learning preferences particularly in relation to developing qualities of learner independence and student directedness. An overall participative approach takes into account the varying information needs of its diverse potential audience. The study design recognised the importance of ensuring that the evaluation had a formative component to allow it to offer an improvement function to the quality of study of the students who participated in the various evaluation measures during their own educational process. The findings demonstrated that the programme was successful in achieving its aims. But post course enquiries into the course graduates initial staff nurse experiences, revealed a marked fall in self confidence when they were first confronted with responsibility and accountability. The high anxiety levels, and fears of 'not knowing' how to carry out more complex procedures led to the recommendation that the initial period of preceptorship should include a supernumerary interval in which the newlv qualified staff nurse could be free to 'catch up' on experiences not encountered during the clinical allocations. It is envisaged that the findings will be of interest to the wider nurse educational arena at both local and national level. It will assist not only nurse education programme planners and those implementing the Project 2000 initiatives but also educationalists in compulsory, further and higher education. Finally as a direct record of the effects of the most fundamental changes in nursing history, it has the potential for becoming a source document for future nurse historians.

This study aimed to explore the effects of a transformatory learning programme in a group of Project 2000 nursing students. A secondary focus of the study was to monitor the effectiveness of reflexive action research as a tool for reducing the theory-practice gap that persists between nurse education and nursing practice. The learning programme was developed around the process of reflection and evaluated within a framework of a hierarchical model of nursing research and critical social theory. The first level of research used formal theory to generate an action strategy with a group of first year student nurses (n=42). The action strategy was evaluated after an initial period of six months and provided the data for the level two research. The level two research facilitated a macro view of the learning situation which was then examined in more detail for the level three research. Reflection on action was adopted as the method of generating informal theory with the aim of facilitating a micro view of the learning environment. Data was collected using a variety of strategies, both within methods and across methods triangulation assisted a holistic view of the phenomena under exploration. The process of transformatory leaning was found to be a notable factor in developing reflective and effective practice amongst student nurses. Additionally, reflexive action research proved an effective strategy for narrowing the theory-practice gap. The insights gained from the study have considerable significance for informing the future practice of teaching in nursing, not least the challenge that teachers, like nurses, have a professional obligation to develop and review their practical knowledge and explore the effectiveness of their practice. It is proposed that reflexive action research and reflective practice are an appropriate formula for addressing these issues.

This thesis develops a policy-oriented account and evaluation of pay determination and associated employment changes for U.K. nursing staff in the 1980s, within an analytical framework for understanding nursing pay processes and outcomes over longer time horizons and with greater generalisability. In particular, an analysis is conducted of the Pay Review Body for Nurses and Midwives and of the interlinkages between pay determination, grading and training at different levels of aggregation. The study is multidisciplinary, employing a wide range of primary documentation, and findings from national-level interviews and local case studies at eight district health authorities in the West Midlands region. The thesis divides into three parts. The first locates nursing pay determination in historical context. Structural characteristics in the health division of labour and in the wider political economy lend a degree of apparent continuity to nursing pay levels. However, this appearance masks important change which must also be understood. The second evaluates the origins of nursing pay review, its processes and outcomes. The conflicting bargaining positions and power relations between the 'Sides' in pay review are noted, together with the continued importance of negotiation and of 'non-pay' issues. The role of the Pay Review Body is considered alongside nursing pay outcomes. Although the Review Body could be seen as contributing to conservative outcomes for nurses' pay, there are complex feedbacks within the system which must also be understood. The third section considers 'non-pay' issues and tne interplay of national and local forces in an evaluation of local managerial perspectives on nurse resourcing and employment changes in the 1980s. It is argued that a 'crisis' occurred in the late 1980s, rooted in history and political economic circumstance, and that the process of pay deceritralisation should be understood in this light. This process, however, is a risky and uncertain one.

A strategic approach, utilising two sequential action research cycles over a two year period, was adopted to prepare teachers in one college for nursing and midwifery for diploma level courses. Ini tially, a link wi th higher education was developed, a policy for staff development implemented, and diploma level courses were planned. A survey of 63 teaching staff revealed their misconceptions about diploma level courses. During the second cycle, conjoint validation and subsequent implementation of diploma level courses were achieved. A staff development progammme was planned and implemented to prepare teachers for new roles and responsibili ties wi th diploma level courses. Five exploratory visits to other colleges of nursing were undertaken to valida te the approach adopted to staff development. Four were in England and one in Norway. Critical incident techniques and semistructured interviews of 7 education managers and a sample of 12 teachers were conducted to evalua te the programme's effectiveness. Teachers had an enhanced awareness of academic level in courses and were more confident to teach at diploma level. They were still inexperienced and uncertain about diploma level assessment and the integration of diploma level intellectual skills into practice settings. Theory has emerged from the research concerning the ongoing development of intellectual skills of nurses and midwives wi thin an academic framework incorpora ting a taxonomy of cognitive skills, self-directed learning and reflective practice. The central component of all these aspects is tha t of cri tical thinking which respondents identified as the characteristic which differentiated diploma level courses from previous training approaches. The eclectic staff development approach within a policy framework including individual performance review, achieved both individual and organisational development and contributed to the creation of corporate identity and cri tical awareness amongst staff. The programme also familiarised teachers with higher education approaches to course delivery prior to the impending merger of nurse education with higher education.

This thesis provides a reflective account of the introduction of a provisional model of transitional learning support (known as preceptorship) offered to newly qualified nurses via an action research project. 284 nurses took part in the project over a three year period. By a process of collaborative exploration, reflection and problem-solving, preceptor partnerships were established in the workplace in an attempt to uncover and articulate the learning and socialisation processes encountered at the beginning stages of a nurse's career. Data relating to the model's implementation was collected via eleven different methods, the most data-rich being that of values exploration and clarification using the dialectical technique of 'Socratic Questioning'. The data and relevant literature were then collaboratively analysed and interpreted by co-researchers using the principles of reflective practice. The emerging account of beginning practice in nursing was then synthesised and 'reconstructed' by the primary researcher, drawing on the theoretical and philosophical perspectives of Social Constructionism and Human Ecology. A practice based theory of preceptorship was developed and empirically tested through the project, and a description and reflective evaluation of the processes involved is provided here. Tentative recommendations are then offered for the future development of preceptorship in the workplace.

The introduction of the Framework and Higher Award (ENB 1991b) provides the opportunity for nurses to claim credits for the knowledge they use in practice. The assumption is, that this is accreditable (ENB 1991). This study aims to identify if this is the case by examining the practical knowledge of 35 expert nurses. Expert nurses were chosen as they are the most likely of all nurses to be using knowledge in their practice which is accreditable at diploma and degree levels. The study was carried out in two Health Authorities, using both quantitative and qualitative methods. The later formed the main contribution to the study. Ethnographic and phenomenological approaches were used to guide the workshops, interviews, observation visits and critical incident collection. Modified grounded theory was used for data analysis. As a result of the inductive nature of the study, emphasis changed from identifying knowledge for accreditation purposes, to exploring the types of knowledge and expertise that emerged from the data. Findings challenge much that had been written about nursing knowledge. A number of issues arise. Questions are raised about the definitive way that expertise is presented in the literature. Also, the assumption that the importation of subject matter knowledge will produce practitioners who provide expert care is challenged. Whilst education is seen as important, it is not sufficient. Other factors in the nurses' 'world view' require consideration. The experts exhibited four different 'world views'. These in turn had an evolutionary effect on knowledge development and knowledge use. Four distinct types of expertise were found to have developed. A number of areas are explored in relation to the practical knowledge experts use and include: organisational culture, doctor-nurse, and management-nurse relationships, academic and professional development, empowerment and reflective ability. Issues relating to advocacy, the theory-practice gap, accreditation, and the quality of patient care, are also examined. Implications arise for curriculum builders, managers, nurses and educationalists.