Introduction. The literature shows that nurses have an important role to play in sleep promotion. There is a lack of literature which has set out to investigate what nurses know or feel about sleep promotion or how they are prepared for this role. Aims. This study explored the educational experiences, knowledge and attitudes of student and registered nurses regarding sleep promotion. Design. A mixed method approach which was partly informed by the principles of ethnography was used. It was carried out over time in 4 phases. Methods. 1. Quantitative descriptive data on sleep input in pre-registration nursing Higher Education Institutions (HEIs) (n=27) collected by postal survey. 2. Questionnaires completed by student volunteers from 4 HEIs (n= 120) in the last 6 months of their nursing programme and by registered nurse volunteers from critical care and care of the elderly backgrounds studying at 4 HEIs (n=98). 3. Interviews carried out with a sample of the students (n=26) and the registered nurses (n=15). 4. Further interviews with 16 of the original students, 6 -12 months post-qualification. Results. The findings showed that there was no standardisation of educational input in the HEIs. The participants felt they had learned most about sleep promotion through clinical experience, from staff, patients and their own life experiences rather than their educational programmes. Their learning was unstructured, learning by being in practice as opposed to reflecting on practice and they lacked declarative knowledge about sleep and its promotion. The participants held generally positive attitudes to sleep but for some there were clear blocks to their practice, including the attitudes of others, ward culture and routine orientation of care, resulting in sleep promotion having a low priority. A model of sleep promotion practice and a characterisation of sleep promoting behaviour were developed from the participants' descriptions and experiences. Conclusions. These findings highlighted the need to address the acquisition of knowledge and skills on sleep and its promotion. A new framework is proposed for this purpose. The clinical implications include the need to increase awareness of all staff, particularly through managers who have responsibility for encouraging positive attitudes towards sleep promotion.

Constipation is common in childhood, rarely life threatening and' therefore might be expected to have little impact on health care provision. The reality is somewhat different, with many children requiring medical and nursing management for this condition that causes great misery and discomfort. Many families consider the use of complementary and or alternative medicine (CAM) as a treatment option when conventional treatment 'fails'. The use of Complementary and Alternative Medicine (CAM) in paediatrics is increasing and is popular with parents/carers but there is currently little evidence to support its use in general and no randomised clinical trials investigating the use of reflexology in children in particular. The thesis presents the development of a randomised controlled study to investigate the effectiveness of reflexology when taught to parents and delivered as adjunct to standard treatment. It includes a systematic review of the literature pertaining to childhood idiopathic constipation and reflexology; the rationale for the choice of method and the development of the clinical trial. The study that was undertaken compared the way in which children with chronic idiopathic constipation (Cre) respond to reflexology treatment or foot massage when these treatments are taught to their parents and carers, and used as part of their standard medical treatment. The optimal way to manage childhood idiopathic constipation is still unknown however this trial has demonstrated that reflexology has a role in improving outcomes for children when taught to parents and used as an adjunct to standard treatment. This is the only RCT of reflexology as practised by parents in paediatric practice to date and further well-designed studies are needed.

Aim: This study explored the nature of supported self-care for women who had lymphoedema associated with breast cancer treatment, and the work of lymphoedema practitioners. Background: Health policy indicated a need to examine the potentially evolving roles of individuals with long term conditions who undertake self-care, and health professionals who provide support. Lymphoedema affects around one in five women who undergo treatment for breast cancer. A woman with lymphoedema can experience long term swelling, most commonly of her arm, affecting her life in various ways. Methods: Three small group discussions were undertaken with women who had lived with lymphoedema for more than two years (n=7). Field observation (n=16) of clinic appointments with women who had lymphoedema, were undertaken alongside interviews (n=15) with eight lymphoedema practitioners. Women who had newly developed lymphoedema (n=10) were interviewed three times over a period of six months. The study was underpinned by social constructionist perspectives, and informed by feminism and relational autonomy theory. Findings: Various structures of power influenced the capacity for supported self-care in women and practitioners. Lymphoedema influenced women's self-identity, and women experienced substantial distress and frustration relating to the initial development of lymphoedema, the chronic nature of the condition, and in adapting to self-care. Lymphoedema practitioners provided support for women from within a mainly bio-medical framework of care, often based within acute clinical settings. Accessing local, trusted information and advice relating to lymphoedema self-care was challenging for some women. Conclusion: An anticipatory approach to supported self-care was identified. The development of reflexivity and self-discovery was considered equally relevant to women with lymphoedema and lymphoedema practitioners. Professional approaches to support should recognise this anticipatory perspective and enable timely access for women to individualised and appropriate support at key points in their lymphoedema trajectory.

Abstract Background Compassionate caring and dignity are key priorities in current policy and research agendas and are central to the quality of experience for patients, families and staff. Developing relationships has been identified as a key component in enabling excellence in caring to be realised in practice. However there is little evidence that identifies the processes involved in delivering compassionate relationship-centred care. This study sought to address this gap in the knowledge base. Aims and research questions The study's aim was to examine and evaluate processes that enhance compassionate relationship-centred care within an older people care setting in an acute hospital. Key objectives were: to develop an understanding of the concept of compassionate relationship-centred care within the practice setting through exploring the views, perceptions and experiences of staff, patients and their families; to develop, implement and evaluate strategies that promote this concept; to examine the processes that need to be put in place to enable sustainability of these strategies; and to identify the lessons learnt to inform practice, education, policy and research. This study was part of a larger programme of work that aimed to integrate compassionate care across practice and education. Approach and methods My role as a senior nurse and practitioner researcher meant that I was in a unique position to be able to capture not just theoretical views of compassion but how this was enacted in practice. To do this the study used the approach of appreciative inquiry. A range of methods was used: participant observation, stories using emotional touchpoints, photo-elicitation, and group discussions to explore beliefs and values. Data were continually fedback to staff participants to involve them in analysis. An iterative and inductive process of immersion crystallization was used to analyse data. Findings A key finding was the development of a practice model to support practitioners to deliver compassionate relationship-centred care. This model suggests that, in order to deliver such care, people need to engage in the process of appreciative caring conversations in order to understand a) who people are and what matters to them; and b) how people feel about their experience. This in turn enables a process of working together to shape the way things are done. The findings support the notion that during these caring conversations the practitioner needs to connect emotionally, be curious, collaborative, able to compromise, considerate of others perspectives, courageous and actively celebrate when practices have worked well in order to promote compassionate relationship-centred care. This framework comprises the 7 ‘C's of caring conversations and makes a unique contribution to the body of knowledge in providing practical guidance as to the ‘how' of compassionate relationship-centred care. Key outcomes of implementing this model were that people felt comfortable to express emotions, developed stronger relationships, were more consistent in delivering compassionate care practice across the team, and had a sense of learned hopefulness in the face of complex and competing demands. Conclusions and implications Implementation of activities in practice to support this way of working revealed that these processes are complex, often requiring the practitioner to takes risks and therefore the provision of appropriate support, facilitation and strong leadership are important factors in helping to sustain such practices. The outcomes of this research build upon the existing knowledge base by providing a practice model that specifies how to deliver compassionate relationship-centred care, and they demonstrate the impact of using appreciative approaches to facilitate improvement within health care contexts.

A longitudinal constructivist grounded theory study was undertaken in Scotland with the aim of exploring the on-going perceptions and experiences of HCAs and PNs withinGeneral Practice following the introduction of the HCA role. Data collection and constant comparative analysis took place within two contrasting regions in Scotland over a two year period with each participant. An emergent theory oF HCA role growth and identity was identified.

Aim: The aim of this study was to provide an understanding of the biographical impact of newly diagnosed Multiple Sclerosis (MS) on the individual and their support person(s) and how this impacts on how the person manages the transition to living with MS. Background: Being diagnosed with a chronic illness is a significant life event which may result in stress for the individual and their family. Previous studies in chronic illness have identified how previously held ideas of the self and identity, which are strongly linked to social roles, are challenged as a consequence of being diagnosed. Methods: The research was underpinned by a hermeneutic phenomenological approach. A focus group with seven MS specialist nurses was conducted to identify the support needs of people newly diagnosed with MS, and their role in providing support and intervention during the period following diagnosis. The data from this focus group then informed the development of the interview guide for the interviews with the people with MS and their support person. Semi-structured interviews with ten people with MS and nine support persons were conducted. The data were analysed using interpretative phenomenological analysis. Findings: The diagnosis of MS created an acute disruption to the taken-for-granted sense of self, both among people with MS and their support persons. The lived experience involved a number of disruptions to daily life which impacted on the identities associated with the many roles individuals had. Key themes were identified which add to existing knowledge by developing the meaning of being diagnosed with MS for the self, and identifying the processes that individuals go through on their journey to living with MS as part of a new biography. The three superordinate themes: ‘Road to diagnosis', ‘The liminal self' and ‘Learning to live with MS: an uncertain future' emerged from the interview data with a cross cutting theme of ‘The impact on the self' for both the person with MS and their support person. The findings captured the lived experience of being diagnosed with MS as close to the time of diagnosis as was possible within the constraints of the study. This has led to a nuanced description of the lived experience which has highlighted the concept of a liminal self in MS. The liminal self describes the experience where the individual's conceptualisation of their taken-for-granted self has become invalid, as the they are faced with new knowledge of their diagnosis of MS which needs to be incorporated into the new self. The uncertainty relating to this condition makes this a difficult and liminal transition. To articulate this new knowledge, I have developed a conceptual framework which builds on previous theoretical positions of chronic illness and biographical theory to further illuminate the understanding of living with MS in the initial stages following diagnosis. This thesis argues for understanding the lived experience of biographical disruption following a diagnosis of MS to be understood in the proposed conceptual framework of ‘Threshold concepts and the liminal self in MS'. The framework has four main components: the ‘preliminal self' which conceptualises the lived experience prior to diagnosis where symptoms of MS are experienced but the cause is not yet known; the ‘threshold concept: being diagnosed' conceptualises the experience of being diagnosed as a pivotal moment in the transition from person with symptoms to person with MS, or partner to potential carer; the ‘Liminal self in MS': conceptualises the lived experience of biographical disruption where the person's sense of self is in transition; the ‘Post-liminal self in MS' conceptualises the reincorporation of the sense of self transforming the self as a person with MS or support person of someone with MS. This experience is subject to on-going uncertainty and as such is never quite stable. Conclusion: The findings from this study highlight the need for health care professionals to recognise the liminal self and consider this in the support of the person with MS and their support person. The conceptual framework, grounded in the data from this study, provides a new way of understanding the lived experience of those affected by a new diagnosis of MS. As such, this framework offers an original contribution to knowledge.

Heart disease is a serious problem for both the individual and society at large. It takes many lives. As an acute cardiac nurse I have spent the bulk of my clinical and research career striving to provide acute cardiac care outwith the historical boundaries of the doctor-led, specialty-based, inpatient setting. The barometer of this work however must be the additive knowledge and consequent impact on practice it has provided to the cardiovascular community through peerreviewed publications. This thesis presents an analysis of the evidence base for contemporary developments in acute cardiac care, including 6 core peerreviewed publications, and 11 supporting publications where I am either primary or secondary author. These publications demonstrate the feasibility, safety and efficacy of programmes of cardiac care which depend on complex clinical decision-making and teamwork by nurses, paramedics and doctors. Critical appraisal of the publications is conducted and the research methodologies and theoretical underpinnings analysed. Strengths and limitations are identified and the implications and impact on clinical practice debated. One of the primary aims of this work is to identify a logical and programmatic approach to the body of work, concordant with and focussing in detail on the patient journey. Potential areas, and plans, for future research are detailed. Key themes such as moving the site of thrombolytic treatment to the Emergency Department (ED), streamlining care for patients presenting to the ED with Acute Coronary Syndromes (ACS), establishing and evolving communication networks between Coronary Care Unit nurses and ambulance paramedics, moving the site of thrombolytic treatment to the ambulance, developing an optimal reperfusion programme including pre-hospital thrombolysis, primary percutaneous coronary intervention and in-hospital thrombolysis, analysis and synthesis of treatment timelines as they are distributed across treatment groups are presented. In totality this work supports the direction of travel towards pre-hospital treatment of ACS. Although this may sound somewhat straightforward it is, and has been, a significant paradigm shift for multidisciplinary clinicians in the United Kingdom. These works in their totality have contributed to defining the optimal contribution of multidisciplinary experts to ACS treatment in the United Kingdom, and in a Scottish context have contributed to national policy and service provision. Finally this thesis does not sit specifically within the confines of “nursing research.” Rather it is defined by healthcare research by a nurse with multidisciplinary colleagues. The practice and research described herein is not confined within artificial boundaries within one discipline. Rather the study is of patient outcomes, systems of care and the contribution of nurses and paramedics to the care of patients with ACS.

Background Hip fracture is a common, serious and well-defined injury which requires early surgical fixation, medical care and rehabilitation. Standards for its prevention and management are clearly defined in national clinical guidelines and standards (SIGN, 2002, NHS QIS, 2004). Despite this, local reports indicate that the experience for older people and their families following hip fracture care was poor. The complex journey following hip fracture care crosses traditional service delivery boundaries, creating challenges for the coordination and integration of health and social care for the older people with this injury. Overall aim The aim of this study was to explore a multidisciplinary collaborative approach to developing practice in hip fracture care. Design and method A collaborative inquiry design was used. A purposive sample of sixteen clinical leaders from different disciplines working with older people with hip fracture met for eight two-hourly action meetings. Included in these meetings were identifying the strengths and limitations of the present hip fracture service, values clarification, creating a shared vision, sharing clinical stories and reviewing a set of case records. To support the process three patients and two carers were interviewed to provide evidence of their experience of care. A reflective journal was kept throughout the study. Findings Facilitation strategies complemented the traditional top-down directive leadership style normally experienced by those involved. This collaborative approach enabled the team to collect and reflect on evidence from different sources helping them learn that psychosocial factors were immensely important in recovery. These included providing continuity of care; giving information and checking understanding; asking if help was needed; ensuring that there was support in place once the older person was home; and being realistic about the time it took to recover following this injury. A key outcome was the team's recognition of the need for integrated working and unified case records.

Nurse education has evolved from an apprenticeship model to one with a graduate focus. However, numerous factors have resulted in less opportunity for students to practice clinical skills in practicum (Scholes et al., 2004). Simulation was introduced to address this (NMC 2007) and research has shown that simulation is effective in the acquisition of skills over the short term (Alinier et al., 2006; Ironside et al., 2009). However, no research had looked at the student experience of simulation over an extended period of time. The aim of this longitudinal qualitative study was to explore the progressive nature of the student nurses' experiences of learning within a simulated clinical environment (SCE) and the impact it had on their learning and transfer of skills to practicum. A purposive sample of twelve students was recruited from two different intakes. Cohort one comprised four students. Cohort two comprised eight. Students consented to being interviewed five times, from entry into the branch programme to registration. Each cohort participated in an initial focus group, one observation in practicum and four semi-structured one–to–one interviews over the course of the two–year branch programme. Data were thematically analysed (Colaizzi 1978), with existing literature used to support or counter emerging themes. A recurring focus was how well students were able to participate in the SCE. What was apparent was that those able to fully engage with the simulation events appeared to get the most out of it. Findings revealed many factors, which facilitated or inhibited student engagement. The categories that emerged were: learning in the simulated clinical environment; authenticity of the simulated clinical environment; concrete experiences in the simulated clinical environment; visual mental model; and practicum experiences. An important recurring factor that was unforeseen was the impact students' preferred learning style could have on their skill development and subsequent transfer to practicum. Findings were returned to participants for verification of accuracy.

Introduction and aim: An estimated 100,000 people in the United Kingdom have percutaneous coronary intervention (PCI) each year to help alleviate angina symptoms. Thereafter, they are expected to modify their coronary heart disease (CHD) risk factors, adhere to medication and effectively manage any recurring angina symptoms. The rate of ‘redo-revascularisation' in PCI patients seems disproportionately high (75%) when compared to patients who have their angina symptoms managed with coronary artery bypass surgery (<20%). PCI patients' self-management may be ineffective, however, existing research on this subject is limited by design (e.g. single methods of data collection), methodology (e.g. samples with patients of mixed diagnoses) and lack of theoretical underpinning. Few theories had been used to help explain self-management in a PCI patient group. Researchers have used Leventhal's Self-Regulation Model to understand how people manage other chronic illnesses but not CHD after elective PCI. Bandura's Social Cognitive Theory was found to be the basis of self-management but had not been used to explain PCI patients' CHD self-management. Consequently these two theories were tested to determine their ability to explain self-management in this PCI patient group. The research questions used for this study were:  How do patients self-manage their CHD after they have undergone elective PCI?  What factors influence patients' self-management of CHD after elective PCI?  To what extent do Bandura's Social Cognitive Theory and Leventhal's Self-Regulatory Model help explain self-management of CHD in patients after elective PCI? Design and method: This mixed methods study used a sequential, explanatory design and recruited a convenience sample of patients (n=93) approximately three months after elective PCI. Quantitative data were collected in Phase 1 by means of a self-administered survey and were subject to univariate and bivariate analysis. Path analysis was also used to identify factors that influenced CHD self-management. Phase 1 findings informed the purposive sampling for Phase 2 where ten participants were selected from the original sample for an in-depth interview. Qualitative data were analysed using thematic analysis. Findings: After PCI, 74% of participants managed their angina symptoms inappropriately and one in five stated that they would consider using emergency care services for any recurrence of angina symptoms. Few patients adopted a healthier lifestyle after PCI: 75% were physically inactive, 65% were obese, and 27% made no lifestyle changes at all. Younger participants and those with threatening perceptions of their CHD were more likely to know how to effectively manage their angina symptoms. More educated, self-efficacious participants with fewer co-morbidities and less threatening perceptions of their illness had a greater likelihood of adopting healthier behaviours. Qualitative analysis revealed that intentional non-adherence to some medicines, particularly statins, was found to be an issue. Some participants felt unsupported by healthcare providers and social networks in relation to their self-management and seemed socially isolated. Others reported strong emotional responses to CHD such as fear, shock and disappointment. This had a detrimental effect on their self-management. Neither the Self-Regulation Model nor the Social Cognitive Theory fully explained CHD self-management after PCI. The emotional perceptions participants had of their CHD influenced their cognition and that affected how they coped with their condition. That finding did not align with the Self-Regulation Model. Aspects of the Social Cognitive Theory helped to explain participants' likelihood of adopting more healthy behaviours but the other components of CHD self-management (manage angina symptoms and adhere to medication) were not explained using this theory. Conclusion: This is the first study to report that patients experienced poor social and healthcare support after elective PCI. Patients had difficulty regulating strong emotions such as fear, shock and disappointment after PCI. This had a detrimental effect on their self-management and neither the Social Cognitive Theory nor the Self-Regulation Model could fully explain CHD self-management after elective PCI. Recommendations for practice / research: Patients after PCI wanted (and should be given) more support to help them manage their CHD yet few accessed or were able to access the traditional means of support: cardiac rehabilitation. Emotional support should be included in such programmes. This is in addition to providing more traditional interventions that focus on: practical support to assist patients in adopting and maintaining healthier behaviours, guidance on angina symptom management and the need for adherence to medication after PCI. Research could be conducted to investigate other means of supporting CHD patients after elective PCI. For example, the effectiveness of telehealth programmes in optimising CHD self-management. An intervention study could be conducted to determine which telehealth programmes are beneficial in optimising CHD self-management. A cohort study could also be considered to explore the effect telehealth has on PCI patients' revascularisation rates, morbidity and mortality.