This thesis examines popular images of nursing and nurses and their relation to issues of professional practice and personal identity in the changing health care climate of post-war Britain. The study explores issues of representation in British films, romantic novels and television programmes, as well as in the recruitment literature produced by the government and the profession. Case studies and autobiographical writings are used to situate these images in the context of personal nursing identities. An analysis of the literature on images of nursing in Britain reveals a dependency on North American empirical research in spite of the very different institutional frameworks of both the media and the health care system in Britain. This thesis contributes a substantive empirical investigation of popular representations of nurses, nursing and nursing life in Britain focusing on popular fictional forms. The thesis argues distinctively that there is a strong correlation between these forms, images used to attract young women to the profession, professional nursing ideologies and models of nursing practice. An analytical focus on representations of class, gender and race reveals a white middle-class feminine ethos underpinning claims to professional autonomy and practice. This image is located as a source of internecine debates and struggles in nursing throughout the post war period. Case studies and autobiographies personalise the political struggles outlined above, placing individual experiences of becoming a nurse in the context of training and working in a rapidly changing health care environment. A history of nursing focusing on the experience of skilled practitioners has yet to be written; this work is an initial contribution to that effort.

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The aim of this study was to assess the impact of research education on the attitudes toward research and use of research findings in practice in a sample of graduate nurses and midwives. It also examined how nurse and midwifery teachers could work collaboratively with clinical staff to enhance their use of research evidence to inform their practice. The main barriers to research utilisation and strategies that could facilitate the use of research findings in nursing and midwifery practice were also explored. The project was carried out in three phases and aspects of the theory of diffusion of innovation and the theory of planned behaviour were used as the theoretical framework to inform data collection. For the first phase, a cross-sectional survey using a self-completed postal questionnaire was sent to 340 graduates. A response rate of 56% was obtained. A large number stated that following graduation, their search and critical appraisal skills had improved, expressed positive attitudes towards research and reported using research findings in practice. The second phase explored further the extent of research utilisation. Semi-structured interviews were conducted with 10 respondents from a range of specialities. All participants claimed that they used research findings to a large extent and provided examples to support their answers. The third phase, using a structured questionnaire, explored strategies that nurse and midwifery teachers could use to help nurses and midwives to improve their use of research findings. Forty link teachers and 62 clinical managers took part. Effective strategies identified included enabling clinical staff to access and critique research papers; run research workshops on site; set up journal clubs or research interest groups and undertake joint research projects.

This thesis describes a three-year study which explored the lived experiences of nurses delivering palliative care, and dying patients receiving palliative care. The aim of the study was to examine the perceptions of patients and nurses regarding palliative care, and in particular, how they described a good palliative care nurse. The study generated interesting and significant findings. The lived experience of dying patients was characterised by maintaining their independence, and remaining in control, even in the latter stages of their illness, as well as wanting to feel safe and secure and being supported by their family and the nurses who were looking after them. Patients wanted palliative nurses to be there for them, by spending time with them, provide comfort, by meeting their needs, and for nurses to listen to their fears. The lived experience of palliative nurses was characterised by effective and ineffective interpersonal communication, the building of therapeutic relationships with dying patients, attempting to control pain and distressing symptoms, endeavouring to work as an effective multi-disciplinary team with their colleagues, and developing knowledge and experience in palliative care. The two most important characteristics of a good palliative nurse, as far as both patients, and nurses, were concerned, was to be interpersonally skilled, in particular the ability to be 'willing to listen', as well as, the need for the nurse to possess personal, humane qualities such as kindness, warmth, compassion and genuineness. Nurses, in particular, perceived that a good nurse should have knowledge, experience and keep up to date via professional development, in addition to, being skilled in controlling pain and distressing symptoms.

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Background: Metastatic spinal cord compression (MSCC) can result in paralysis and is an oncology emergency. Prognosis is poor if not treated early. There are an estimated 1200-2500 new cases of MSCC per year in Scotland. At 2013 there are limited studies which have explored the issues experienced by patients, carers and/or family members and healthcare professionals in the management of MSCC. Aim: The aim of this study was to explore the perceptions and experiences of patients, carers and/or family members and healthcare professionals in the management of metastatic spinal cord compression. Research Design and Methods: A case study design approach involving two phases was used. Phase One involved three focus groups with healthcare professionals (n=25) and one-to-one interviews with healthcare professionals (n=7). Phase Two involved interviews with patients (n=8), carers (n=6) and healthcare professionals (n=42). Patients and carers were interviewed twice over a period of six months. Braun and Clarke's (2006) thematic inductive-data approach was used for data analysis. Findings: Phase One identified an overarching theme of ‘negotiating the care pathway' with four main themes: what can we do for patients with MSCC; what do we need to ‘trade-off' to meet the needs of patients; how can guidelines help anyway; and how can we deliver optimum care in the midst of uncertainty? The majority of healthcare professionals viewed the existing National Institute for Clinical Excellence (NICE) guidelines (2008) as inadequate and lacking in a strong evidence base. Healthcare professionals acknowledged the importance of meeting the patient's preferred needs and goals given the nature of this condition and the short life expectancy of many patients with MSCC. Phase Two identified three main themes: facing uncertainty in MSCC; finding a balance in MSCC and support beyond the treatment of MSCC. A focus on acute management is often at odds with the palliative nature of the patient's condition and this contributes to the complexity for patients, carers and healthcare professionals. The findings demonstrate the intricacies of uncertainty which affect all the key stakeholders when MSCC presents. There is a constant movement between uncertainty (of the future) and enduring inconsistencies (of information, treatment and advice for the future), which results in a struggle to find a balance. Conclusions: Caring for patients with metastatic spinal cord compression is challenging with uncertainties surrounding the diagnosis of MSCC, spinal instability, treatment and support beyond the treatment of MSCC. A theory of collaborative decision making based on the findings in this thesis is proposed to help reduce uncertainty and enable key stakeholders to make decisions in their journey with MSCC.

Approximately 550,000–570,000 women are alive in the UK who have had a diagnosis of breast cancer with further predictions that this will rise by 3% annually. Most of these women will be receiving follow-up care in a hospital setting and the value of this approach has been questioned for a number of years. Women transition from a very individual, personalised treatment plan to follow-up care which is not organised around individual patient need. Rather a blanket approach is used which does not consider age, risk profile, treatment or need. There is evidence that the current out-patient follow-up provision does not meet the physical, psychological and information needs of women with breast cancer, with women leaving the clinic with unmet needs. While the aim of follow-up is multifactorial, including the provision of psychosocial care, there is little evidence of how this service assesses and addresses unmet needs. Aim The current study sought to examine the effectiveness of providing patient reported needs and psychosocial information to the Specialist Breast Care Nurse at the breast cancer follow-up clinic in reducing cancer needs and improving quality of life compared to standard care. The primary outcome was a change in needs scored at baseline (time 1) and 12 months (time 2). The study also aimed to investigate a number of secondary outcomes namely changes in quality of life at baseline and 12 months, as well as looking at possible effects of the intervention on variables such as age, severity of treatment and time since diagnosis. Method This study was a prospective single blind randomised controlled trial (RCT) involving 93 women who had completed primary treatment for breast cancer and were attending follow-up in a hospital setting. Women were randomised to receive standard follow-up care (control) or a nurse-delivered intervention. The intervention was structured and guided by the self-reported needs and psychosocial information provided by the woman and coupled with a person-centred conversation. This conversation explored the options for the intervention, desire of the woman for assistance and best way to provide it. Results There were high levels of need, anxiety and depression among women attending the follow-up clinic. There was a statistically significant fall in level of need, anxiety and depression in both groups after the intervention. However, no differences between groups in relation to the primary outcome; changes in needs between baseline and time 2, were seen. Quality of life scores fell in both groups; however only the overall quality of life score showed a statistically significant difference between groups in relation to the secondary outcome, changes in quality of life over time. Conclusion The results of this study have shown that using patient-reported needs and psychological information by the specialist breast care nurse in the follow-up clinic to inform an intervention proved to be no better than standard care, but neither is there sufficient evidence to state it was worse. This study has contributed to the methodological evidence base regarding the development and measurement of complex interventions in nursing practice.

The methodology of meta-analysis of diagnostic studies is underdeveloped compared to that of randomised controlled trials. However, summarising evidence from diagnostic studies is important, and interest is growing in diagnostic study meta-analysis. Current recommendations are to use summary receiver operating characteristic (SROC) curve methods, in particular the bivariate or Hierarchical SROC (HSROC) methods, which share many statistical properties. These methods have been little used as they are recent developments requiring statistical expertise. To test these methods, a systematic review on the diagnosis of carotid stenosis by four noninvasive tests was undertaken to provide data for the SROC curve methods. Both the bivariate and HSROC methods failed for all four tests. Further investigation of the behaviour of the SROC curve methods, in particular why they did not work for a large proportion of datasets, was undertaken in a simulation study. This found a failure rate of 50%. Failure of the SROC curve methods was more likely when the individual studies were small and the average sensitivity or specificity was high, and these are characteristics of real studies. The DiagMeta package was developed for use in R, a freely available software package —for use by reviewers who may lack methodological expertise —with guidance on when the SROC curve model fails and alternative analyses. Finally, an empirical comparison was made between individual studies' receiver operating characteristic (ROC) curves and their SROC curve. Even when ameta-analysis can be successfully performed, the resulting SROC curve is difficult to interpret and may not lie close to the individual studies' ROC curves. The SROC curve model is difficult to fit and can limited by the data. Reviewers should therefore try to obtain as much data as possible prior to meta-analysis.

This thesis offers an original contribution to knowledge through providing a rigorous longitudinal examination of a complex intervention known as the ‘Leadership in Compassionate Care Programme' (LCC) which was designed to embed compassionate care within local NHS practice in a large Health Board in Scotland. To date there has been little research into the impact of dedicated programmes aimed at enhancing compassionate care on an organisational basis. Through the use of Pawson and Tilley's (1997) realistic evaluation framework this study takes the form of a critical exploration of what did and did not support a sustained focus on compassionate care within the participating settings. The findings have important implications for both policy and practice, and the thesis culminates in a series of recommendations for healthcare organisations at macro, meso and micro levels. Concern about the delivery of compassionate care in the NHS has become a major focus of political, public and professional debate during the last ten years. There has been long standing recognition of the clinical and financial pressures within the NHS; however, the scandal of poor care in Mid Staffordshire NHS Trust brought the issue of compassionate nursing practice into sharp focus. This study makes reference to the findings of the original Francis Inquiry (2010) and subsequent recommendations (Francis 2013) and there is no doubt that the current and future landscape of compassionate care is very different to the one encountered at the outset of this inquiry in 2007. This longitudinal qualitative study provides insight into nurses' experiences as they engaged with the LCC Programme and it provides an important understanding of how best to recognise and support existing good practice and achieve sustainable improvements. Data collection was conducted over three years and primarily involved 46 semi-structured interviews with 33 key participants. This led to the development of eight detailed case studies of participating wards and the generation of an analytic framework based on ‘level of adoption' of the LCC Programme. The eventual synthesis of findings across all eight study sites permitted the development of a conceptual model for strengthening organisational capacity for the delivery of compassionate care. The ‘compassionate core' of this model recognises compassionate care as focussed on meeting the needs of patients, of relatives and of staff. My findings point to the fact that embedding and sustaining compassionate care demands a strategic vision and investment in a local infrastructure that supports relationship-centred care, practice development, and effective leadership at all levels.

Introduction Measuring consumer expectations and perceptions of service provision is supported by both practitioners and academics. The National Health Service, as a result of policy reforms and structural changes, recognises the role of the patient in health care and is gradually incorporating patient views in policy and practice. This study explores the experience of the patient and its affect on the expectations and perceptions of the service provision. Two hospitals, antenatal and postnatal groups were utilised to ascertain the views and experiences of pregnant and recently delivered women. Methodology Focus groups were held with women who had delivered, since the implementation of the Patient's Charter, to establish the expectations of the women using the service provision. Issues of priority to these women and the perception of their overall service experience were also considered. In-depth interviews were then conducted with pregnant women to identify expectations of their forthcoming delivery and subsequent in-depth interviews were conducted with the same women once they had delivered their children. This was to evaluate their perceptions and compare them with their initial expectations. Finally, key themes and recurrent ideas were tested, using hypotheses developed after the qualitative research. The questionnaire approach was to substantiate or discount the findings of the first two stages of the research. Dissemination Familiar service quality attributes were recognisable from the analysis of the comments. Although there were issues on which women agreed unanimously, many elements of the service provision were viewed differently by women with experience and women from varying categories of residential area. The results also demonstrated that the use and dependence of referent groups varied between the women and that this was imperative for communication. Statistically, the use of referent groups, substantiated through the questionnaire analysis, provided significant results to support the initial findings. Contribution Using the information from the qualitative research, a Maternity User's Matrix was developed identifying key characteristics of users' of this service provision. The significant results from the quantitative research were used to develop an existing consumer behaviour model. Using expectations, levels of satisfaction and perceptions of consumers, this research has implications for service provision, health practice, future research and service itself.