Anorexia nervosa is a serious, life threatening mental disorder that is difficult to treat. Research suggests that the therapeutic relationship is an aspect of therapy that is valued by recipients of eating disorder services and viewed as essential in the quality of any treatment undertaken. Establishing a helpful therapeutic relationship can be equally challenging for both the therapist and the client. Additionally, what the nature of the therapeutic relationship needs to be is often unclear and there is limited research into this aspect of the therapeutic relationship from the perspective of adults with anorexia nervosa specifically. Therefore, the aim of this study set out to answer the research question: • What is the nature and context of the therapeutic relationship from the perspective of adults with anorexia nervosa? Following a constructivist grounded theory methodology, elicited written data were gathered from adults with anorexia nervosa using asynchronous online research methods via a bespoke confidential website. The participants were recruited through the eating disorder charity Beat. Additional existing autobiographical material including books and online blogs were also used as supplementary data. Data collection and analysis was carried out over three phases. Three theoretical categories were constructed that explicate the significant aspects of a positive therapeutic relationship: Balancing control in the therapeutic relationship; Developing trust; and “They just got me” - feeling understood by the therapist. The central category of individuality or “one size doesn’t fit all” underpins these categories, hence requiring a therapist to tailor the therapeutic relationship to the individual. In conclusion, this study offers a substantive theoretical understanding of the critical aspects of the therapeutic relationship as described by adults with anorexia nervosa. These factors have utility across a range of recommended psychological therapies for anorexia nervosa and could be usefully deployed by any health, social care or education professional.

Background: Domestic abuse is a global public health issue which results in wide ranging health consequences. There is an increased risk of domestic abuse in pregnancy and the post-natal period. In the UK, health visitors provide a public health nursing service to all families with young children, through regular contact from birth until the child starts school. Health visitors therefore, appear well placed to identify, support and protect women experiencing domestic abuse. Study Aim: This study sought to describe the health visitor response to women experiencing domestic abuse in Scotland and to investigate the experience of the recipients of this response, in particular, women involved in domestic incidents reported to the police. Methods: A mixed research methods approach was employed. Data were collected in three NHS Board areas in Scotland. Data collection included; focus groups with practicing health visitors (n=20); semi-structured interviews with health visitor service users involved in police reported domestic incidents (n=17) and a secondary analysis of routinely collected police data (n=100). Results: Health visitors stated that women rarely disclosed experience of domestic abuse or requested support. Further, health visitors stated that women involved in police incidents were rarely experiencing ongoing domestic abuse. In contrast, the secondary analysis of the police data found that women involved in domestic incidents reported to the police had often been involved in more than one incident (79%); been injured during the incident (40%) and that children were often aware of the abuse (41%). Similarly, the majority of health visitor service users involved in police-reported incidents described experience of ongoing domestic abuse, which children were frequently exposed to, and a health visitor response which did not address their experience of abuse or support needs. Integration of research findings identified challenges to responding to survivors which included lack of a trusting relationship between health visitor and service user, health visitor practice, influenced by organisational issues, such as a child-focused approach and service constraints, and the consequences of domestic abuse for service users including fear of violent repercussions and fear of loss of their children. Conclusion: This study provides new evidence that domestic abuse is often not identified by health visitors and that when abuse is identified, the service response rarely meets the needs of service users. The findings support existing research which indicates a lack of trust between health visitors and service users and provide new insight to the interaction between them. Recommendations from this study are that service responses aim to address the consequences of abuse to effectively engage with survivors of abuse.

Aim To explore the experiences of women with Type 1 diabetes during the menopausal transition using a grounded theory approach and, from the data, develop a substantive theory that will have potential implications for service users and service providers. Methods A qualitative exploratory research framework was employed using grounded theory as an approach. Data were collected from 10 participants using transcribed audio-taped semi-structured interviews and field notes. The transcripts, audio recordings and field notes were reviewed and a coding process facilitated data analysis. Results A wide range of conceptions was revealed. Data are presented in seven categories that reflect the experience of the menopausal transition for women with Type 1 diabetes: ‘Blank wall' (relates to the lack of information regarding menopause and diabetes), ‘Juggling game' (relates to glycaemic control), Anxiety and fear, Self-management, ‘Haywire' (relates to the signs and symptoms of menopausal transition), Treating symptoms, Depression and mood, ‘I'm old' (relates to aging and mortality). Conclusion What emerged from the study is a substantive theory in which absence of information regarding the menopause and its impact on Type 1 diabetes (blank wall) was identified as the main problem facing women with Type 1 diabetes during their menopausal transition. The findings may enable practitioners to identify the types of information, advice and support that should be made available to these women and contributes to the limited knowledge base currently available. The findings indicate also that further research into this under-studied but important area of diabetes care is required.

Background: In the context of increasing survivorship from critical illness it is important to enhance our understanding of the subjective experience of survivors and their families. The critical illness experience is enormously complex, varied and multifaceted. The need to consider the legacy of critical care beyond physiological survival is imperative. Aims of the study: The study aimed to formulate a substantive, middle range theory in relation to patient and family’s critical illness trajectory. Further, to discern and understand the responses of critical care nurses to survivorship needs. Methods: Working within a relativist ontology and a constructivist grounded theory methodology, a series of in-depth interviews were undertaken with survivors of critical illness (n=16), family members (n=15) (phase 1) and critical care nurses (n=11) (phase 2). Interviews were undertaken in a District General Hospital setting in England. All interviews were transcribed verbatim. Constant comparative analysis and data collection occurring concurrently with theoretical sampling commencing from the outset. Findings: Survivors of critical illness invariably entered a liminal state between life and death on admission and during their stay in the Adult General Critical Care Unit (AGCCU). They frequently experienced vivid, hallucinatory experiences which placed them in a different world or liminal space where they could move or transcend in and out of different realities or worlds. The core difficulty can be summarised as follows; survivors have little recall of the factual events of their critical illness within AGCCU but relatives have lived the whole event in a very real and ingraining manner. This can result in family members and survivors experiencing totally different versions or narratives of the critical illness episode; constructing the concept of dualistic worlds. Nurses working within AGCCU found themselves bounded by the walls of the critical care unit and experienced personal and professional conflicts in their role, as they bear witness to critically ill patients and their families. The critical care environment was identified as a demanding place of work which appeared to limit nurses to immediacy of care in the here and now. The specialist knowledge and skill that nurses provided were central to physiological survival but they are unable to support the onward survivorship trajectory. Conclusion: Survivors of critical illness, together with family members experience numerous challenges and adversities when endeavouring to readjust to life post critical care. This study has identified a middle range theory of dualistic worlds between and within the survivor and family member experiences. These temporal events occur during and after critical illness and expose a non-linear, fluid journey towards a new normal. Exploring the dynamic interplay between intrapersonal, interpersonal and societal factors has provided theoretical insights into critical illness survivorship and the legacy of critical care. Nurses in AGCCU bear witness to the early stages of the survivorship trajectory and provide complex care in support of survival; however they, are bounded by the walls of AGCCU such is the proximity to death and the pressure of work. They are unable to support the onward survivorship journey.

No description available.

Seven families took part in a phenomenological study to consider the effects on family life when a parent has chronic renal failure. This is a topic which has not attracted much attention, possibly because the incidence of renal failure increases with age, and as such, young families where there is parental chronic renal failure do not make a major contribution to the workload of a renal unit. Therefore their needs are not necessarily to the fore. In looking at family life there is an acknowledgement of the fact that, for the majority of people, there is a life outside their chronic illness and hospital appointments and there is a need therefore to incorporate this other life into planning their care. It is therefore suggested that a worthwhile approach would be that of family centred care, more commonly seen within the paediatric domain, but here taken from the view of the adult at the centre, rather than the more usual centrality of the child. From the study three central themes emerged: · Normality in family life · Living with uncertainty · Protecting the family. Overarching these themes the ‘life view’ of the parents was important. This is a common thread in all the themes and affects the way in which the parents approach their life. This, in turn, affects how the children from this study are involved in family discussions, about the influence of chronic renal failure on their family. This ‘life view’ fits well with Paterson’s (2001) shifting perspectives model of chronic illness. In this study it is argued that to meet the needs of the family the information provided needs to be congruent with the ‘life view’ of the parent. This, combined with a family centred approach, is the best strategy to facilitate the sharing of information with the children.

This thesis explores the concept of reflection as it exists within the discipline of nursing. It focuses on the social construction of reflection through a post-registration, palliative care programme in the UK. An interpretive ethnographic approach was used to study organisational, contextual and cultural issues, explore teaching and learning interactions and learn more about reflection from student and teacher participants. This was achieved by using ethnographic tools to collect data from observations of teaching and learning; interviews with participants; and extracts from programme documentation and reflective learning contracts. The thesis portrays a programme culture committed to reflection as a valuable way of helping nurses make sense of their practice and make a difference to it. Reflection in order to make sense of practice was constructed by participants as a way of ‘being’ rather than simply ‘thinking’ or ‘doing’, since it intertwined propositional, affective and active elements. This process of reflective ‘being’ within the study was apparently associated with a humanistic approach to nursing, which emphasises the importance of actively using and expressing oneself in order to care for people. Reflection took place through verbal and written dialogue about practice and required both support and challenge. This was achieved through collaborative facilitation from teachers, clinical supervisors and peers, in addition to largely positive education and clinical environments which supported the development of reflection. It was through this reflective education that the programme was educating nurses to learn a language through which to communicate and liberate their practice knowledge with ‘confident, authentic’ voices. Thus learning a language of reflection was important to nurses in order to: articulate their professional knowledge to others; develop meaningful practice; liberate their learning, and consequently attempt to make an active, positive difference to patient care. In conclusion, by adopting an approach focused on exploring reflection through its social construction, this study has contributed further knowledge about nurses’ use of the concept and what it means to them. The thesis argues that there is an inextricable link between how nurses construct the meaning of reflection and their concepts of nursing. It also indicates the significant influence of skilled, collaborative teachers and both education and clinical environments to the use and development of reflection. In addition, it contributes further understanding to the process of teaching and learning about reflection including: support and challenge through facilitation; the necessity of dialogue for reflection; and the ultimate requirement for nurses to find ways to communicate their practice in ways that have authenticity and currency in modern healthcare.

No description available.

Abstract Postnatal depression (PND) is a psychiatric condition that is estimated to affect 15% of postnatal women. Health visitors (HVs) are the key public health professionals involved in its early detection and treating its mild to moderate forms. It has been suggested that some HVs do not assess women for PND and consequently these women do not get the care they need. Equally other women have clearly been shown to benefit from the advice and treatment they get when HVs have discovered PND. Such inequalities are unfair and unjust since they might be avoidable. Unfair and unjust inequality is known as inequity. This study was designed to examine the factors that promote or hinder equity in health visiting PND services and it was anticipated that in doing so a greater understanding ofthe concept and nature of equity in service provision and access to services would be achieved. A qualitative case study approach was used to study one PCTs health visiting PND service. HVs were observed doing 21 home visits to antenatal and postnatal women. Post-observation interviews were conducted with 16 HVs. Nine Bengali women and 12 English women were interviewed. Additionally 10 interviews were conducted with health visiting managers and other personnel involved in the health visiting PND service. In total, 51 interviews were conducted. Documentary data in the form ofthe PCTs PND Strategy Policy were used in two principal ways. Firstly, they provided contextual information, and secondly they provided a framework for the interviews and sampling the observations. The policy documents underwent a critical analysis and the remaining data were analysed using Ritchie and Spencer's (1994) Framework Analysis method. The findings 'revealed that despite the existence ofa policy to provide 'equal and ' equitable' health visiting PND services, many factors led to inequity in service provision. Whilst PND training had been provided to all HVs, it was inadequate in preparing them to detect and manage PND in Bengali women or understand fully the needs of English women from low socio-economic backgrounds. Problems in the policy process led to a situation where managers and HVs were not always aware that the policy to detect and manage PND in all women was active. Furthermore, ambiguous reference was made in policy documentation implying that groups such as minority ethnic women, were issues for future consideration. Constraints such as the lack of appropriate training, other pressing priorities, and the scarcity ofculturally appropriate resources, made it'difficult to provide an equitable service to all women. The research makes a contribution to knowledge by improving understanding of the nature of equity and equality and PND, particularly from the perspectives of lower socio-economic English women and Bengali women. The findings from the policy analysis process will also facilitate the development of policy and culturally sensitive HV practice and the enhancement ofPND services. Ritchie J, Spencer L. (1994). Qualitative data analysis for applied research In Bryman A, Burgess RG (Eds). Analysing Qualitative Data. Routledge. London

Background: A traumatic brain injury is a potentially devastating injury. The family responds to this injury by supporting the individual and their recovery but is perceived as being at risk from the challenge of meeting both new and existing demands. While the perspective of individual family members has been well documented there is growing interest in how the family as a whole makes sense of their experiences and how these experiences change over time. Research Questions: What are the changes reported by non-injured family members during the first year of a family member’s traumatic brain injury? And: within one family what are the effects of traumatic brain injury up to one year following injury? Methods: A longitudinal narrative case-study design used in-depth qualitative interviews and a structured questionnaire. Nine non-injured family members from three families were recruited and data collection took place at one, three and twelve months post-injury. Analysis was completed on three levels: the individual, the family and between family cases. Narrative Findings: Trauma, recovery, autobiographical, suffering and family narrative threads were identified. Narratives emphasised that the year post-head injury was a turbulent time where family members were active agents in the process of change. Quantitative Findings: Data suggested that families recruited to this study had healthy levels of family functioning and these characteristics were sustained in the year post-injury. Discussion: It is possible that although the structured measure suggested family functioning stayed relatively stable these families were embarking on a series of changes to enable this to occur. The significance of these less obvious changes needs to be acknowledged. Conclusion: Working with families to validate their experience, resolve their trauma and prevent suffering may go some way to enabling family members to positively adjust to life in the wake of head injury.