Modem Vocational Rehabilitation Programmes support individuals with Acquired Brain Injury (ABI) by using Job coaches who provide support both in placements and employment. This has improved return to work to around 70% compared to around 20 - 50% previously. But the reasons for success of this supportive process are not clear. Quantitative studies have attempted to correlate factors associated with employment, but results have been variable and conflicting. Long term data regarding sustaining employment is sparse. An exploratory study reported that around 26% of those who return to work could not sustain employment. Job coaches reported that this occurred because of dysfunctional interpersonal relationships (misinterpretation of social cues, interpersonal conflict and inappropriate verbalization), substance abuse, criminal activity, poor employment settings and economic disincentives. This study was built on the exploratory data and examined the area of sustaining employment in detail with the aim of developing a conceptual model. A flexible, eclectic design based on multiple case studies was used. Eight individuals with ABI were purposively selected along with a family member, employer or co-worker and job coach. Triangulation, respondent validation, peer debriefing and reflexivity were used to reduce bias and improve validity. Twenty nine semi-structured interviews were conducted. Transcripts were analysed for topics which were directly linked to sustained employment. Ideas which were directly associated by text were extracted. These concepts were used to develop a conceptual model. Bo-psychological concepts which helped to sustain employment emerged from the research. This included the beneficial use of unconditional motivation, coping skills and pre-injury work and leisure interests. Pre-injury interests also demonstrably improved motivation. Social concepts re-emphasised support from the employer or co-worker, support from the vocational rehabilitation programme and from the work place. An opt-out follow up pattern was proposed i.e. follow up is continued until individuals with ABI choose to opt out. The conceptual model proposes a cyclical continuum rather than a staged and linear approach. It advocates a greater role for employers and co-workers (pre and post-injury) in the process of employment. The conceptual model challenges current practice: it recommends assessments of bio-psychological factors. It advocates greater integration at all levels. It also opens out research challenges in the areas of development of assessment tools for bio-psychological factors, comparison with services available for the unemployed in the general population and transferability of these findings to other projects and similar situations in ABI rehabilitation. It challenges current perceptions by demonstrating that individuals with ABI can be outstanding employees.

Background: It has been suggested that compassion is aspirational, rather than a reflection of the reality of contemporary nursing practice. This notion is reflected through reported negative experiences of nursing care, encountered by individuals across a range of age groups and care contexts. In response, a political and professional reaffirmation has ensued to declare that compassion remains a core philosophy of nursing, although this provides limited articulation of what compassion entails. Furthermore, there is limited empirical research to explore compassion exclusively through the perceptions of individuals who have experienced nursing care, highlighting a gap in existing knowledge. Aim: The aim of the research was to address this gap in knowledge and develop a more comprehensive understanding of compassion in nursing. Specifically, the research aimed to explore compassion, exclusively, through the perceptions of individuals who had personal experience of nursing care. Methodology and Methods: A constructivist grounded theory methodology was implemented, influenced by the theoretical perspectives of symbolic interactionism and social constructionism. The target sample population comprised a group of individuals who were in an established role to contribute to teaching and learning strategies to undergraduate health students within the university setting. Applying a theoretical sampling strategy, data was collected via eleven individual interviews, a focus group discussion with three participants and three additional individual interviews. Data was analysed using initial, focused and advanced coding techniques, supported by constant comparative analysis. Findings: Five data categories were generated from analysis. This comprised the four major categories of Self-Propensity for Compassion, Attributes for Compassion, Socialising for Compassion, Conditions for Compassion and the core category of Humanising for Compassion. Advancing reflexivity to consider these data categories at a more conceptual level identified that compassion was fundamentally characterised by experiences of humanising approaches to nursing care, which were dependent upon the equilibrium of five interrelated elements of compassion. These elements comprised Character for Compassion, Competence for Compassion, Motivation for Compassion, Connecting for Compassion and Action for Compassion. The five elements of compassion were subject to further influence by three overarching principal dimensions of compassion, which comprised Compassionate Self, Compassionate Interactions with Others and Compassionate Situational Contexts. In order to reflect participant perceptions of the complex nature of compassion, a grounded theory was constructed and assimilated into The Model of Compassion for Humanising Nursing Care. The new theoretical insight gained from this model provides a more comprehensive understanding of what compassion in nursing involves, offering an original contribution to the existing knowledge base and a foundation from which to address emerging implications for practice and opportunities for future research.

Background There will be approximately four million people living with cancer in the United Kingdom (UK) by 2030. The National Health Service faces a major challenge meeting the support needs of this growing population, who commonly report feeling isolated and lacking social support. Approximately 45 million adults in the UK use the internet, and online communities might be a culturally relevant way to connect people affected by cancer, allowing them to support one another. However, internet communication is fraught with challenges such as misleading or untrustworthy information. We have a limited understanding of how people experience these communities and whether they can provide meaningful support for people affected by cancer. Aims To explore and understand the experiences and interactions of people affected by cancer who visit online cancer communities. Methods This was a qualitative study involving 23 people who had visited online cancer communities. Participants were affected by a range of cancers and were a combination of cancer survivors and families members. Semi-structured interviews elicited participants’ experiences, preferences and perceived consequences of using online communities. Data analysis was guided by principles of Constructivist Grounded Theory. Findings Participants used communities to ‘navigate’ the challenges they faced with cancer. This navigation produced three categories of experience in online communities. Firstly, advice from fellow community members set participants on a ‘journey to become informed’. Secondly, participants were cast into a ‘journey to recreate identity’ as they connected and formed friendships online. Thirdly, participants discovered a ‘journey through different online worlds’ to the most relevant and often hidden social communities. Conclusions This was the first qualitative in-depth study exploring how contemporary online cancer communities are used by people affected by cancer. Online communities offered multifaceted opportunities to support the cancer experience, and they may promote self-management in cancer care. These findings can inform and improve the delivery of existing online communities.

Background: UK ambulance clinicians are able only to terminate resuscitation attempts that have resulted in an asystolic (flat line) cardiac rhythm, following twenty minutes of advanced life support. All other attempted resuscitations must be transported to hospital for further treatment. Despite this, there are still large numbers of patients transported to hospital who do not survive. Thirteen studies were identified that purported to validate termination of resuscitation guidelines. This evidence could not be used to reduce the number of futile transportations to hospital of adult cardiac arrests of presumed cardiac aetiology within the geographical area of interest, due the variances in emergency medical systems. Methods: Binominal logistic regression identified variables associated with outcomes in a dataset of 4,870 adult cardiac arrests of presumed cardiac aetiology (Phase 1). The clinical decision rule was validated retrospectively against an independent dataset of 2139 patients (Phase 2). It was then validated prospectively (Phase 3). Finally, the financial benefit of introducing the guideline was assessed. Assumptions were made on the potential resources required to treat each patient and the impact from an acute care perspective was assessed as the difference in cost when applying the guideline, compared to current practice. Results: The clinical decision rule (terminate on scene if the initial rhythm was not shockable and there is no return of circulation) was shown in Phase 1 to have a specificity of 99.0% (95% CI: 97.7% to 99.7%) and sensitivity of 53.1% (95% CI: 51.6% to 54.6%). The transport rate was 52.4%. There were five (0.2%) unexpected survivors. This compared favourably with existing guidelines. In Phase 2 the guideline recommended termination for 832 patients. Of these, 829 (99.6%) died and three (0.4%) survived (Specificity = 99.1%, 95% CI: 97.4% to 99.8%, Sensitivity = 46.5%; 95% CI: 44.1% to 48.8%). The transportation rate was 60.7%, which was lower than for existing guidelines when applied to the same dataset. Of 656 patients in Phase 3, the guideline recommended termination of 162 patients. None of these survived to hospital discharge (Specificity = 100%, 95% CI: 95.6% to 100%, sensitivity = 29.3%, 95% CI: 25.6% to 33.4%). The transportation rate during this phase was 75.3%. When plotted on a ROC space, the guideline showed better predictive power, when compared to existing guidelines. The minimum cost saving was shown to be £33,739 per 1000 adult OHCA patients currently transported to hospital. Conclusion: Introducing the decision rule to the trust in question would reduce the number of transportations to hospital of adult patients suffering cardiac arrest of presumed cardiac aetiology. Further research is needed to apply the findings to other locations or emergency medical systems. In order to strengthen the validity of the tool, it should be assessed prospectively in either one large prospective study or several smaller studies, but within different settings. Ideally, to prevent bias, such a validation would be performed by a different research group.

Background - Falls are a major cause of disability and the leading cause of mortality due to injury in people over 75 years living in the UK. Falling in hospital is a significant problem, with falls rates almost three times higher than community-dwelling populations. Interventions effective in the community are not necessarily transferable to an in-patient setting. Aims - The primary aim of the research was to facilitate changes to in-patient rehabilitation services for older people, with a focus on improving falls prevention by exploring patients’ experiences and collaborating with NHS staff. Method - This qualitative action research study had two cycles. In the first cycle, semi-structured interviews were conducted to gain an understanding of the experiences of in-patients who had fallen. In the second cycle, ward staff participated in educational focus group sessions. Findings - The adherence to patient safety and risk management after a fall formed a priority for ward staff which affected the promotion of patients’ independent functioning. The consequences of falling, particularly psycho-social issues such as low self-efficacy and reduced confidence, and restrictions to mobility due to fear were reinforced by the actions of the staff. This resulted in a change in the expected pathway of patients receiving rehabilitation, which prevented them from achieving optimal functioning. Staff identified that inadequate staffing levels affected the rehabilitation ethos. This was compounded by poor relationships and team-working practices. Discussion/Conclusion - The patients’ and staff’s voices of experience demonstrated a range of attitudes, beliefs and behaviours that were either in harmony (resonance) or opposition (dissonance) to each other. Increasing the resonance offered opportunities for service improvement. This study was unique in its focus on two areas of falls research where there is a lack of evidence: patients’ experiences of falling in hospital and interprofessional collaboration for service improvement for in-patient falls prevention. Recommendations to improve Trust practice included greater involvement of patients in decision-making and falls management; adherence to effective team-working practices; and engaging in opportunities to enhance professional learning through falls documentation and monitoring.

The provision of enteral feeding continues to increase with approximately 20,000 people in the United Kingdom feeding at home. Health care professionals have an ethical duty to recognise and treat malnutrition, though in clinical practice they are often faced with difficult decisions to ensure that the benefits of tube feeding are greater than the burdens; that the provision of a tube feed is in the patient's best interests. The aim of this study was to evaluate how the provision of enteral nutrition via a Percutaneous Endoscopic Gastrostomy (PEG) impacts on the Quality of Life (QoL) of patients from the patients' and carers' perspectives. Initially, QoL was measured using the SF36 Health questionnaire. A longitudinal, prospective pilot study was undertaken including clinical and QoL assessments prior to PEG placement, and at one week, one month, three months and six months following PEG insertion. The results of the pilot study of 22 patients clearly demonstrated that the SF-36 was not an appropriate tool for measuring QoL in this patient group. A semi-structured interview approach was developed to determine the concerns relating to PEG feeding and how feeding impacted on QoL. Health care professionals' views were also sought using a postal questionnaire and the results compared to those of patients and carers. These data informed the development of a preliminary QoL assessment tool which involved item generation, item reduction, response scale generation and pre-testing for acceptability and feasibility. Sixteen adult patients, 27 carers of adults and 24 carers of children were interviewed. In general, patients living in their own home viewed their QoL as acceptable. However, the carers of adult patients were less positive about the patients QoL. In contrast, the carers of children frequently reported their child's QoL to be acceptable. The reported impact of feeding on daily and social lives ranged from the PEG feeding being totally disruptive to the PEG having no impact at all. Delayed and disturbed sleep, restricted ability to go out, difficulties finding a place outside the home to feed, childcare problems, the negative attitudes of others towards feeding and family divisions emerged as key issues and concerns. A wide range of feelings towards the PEG feeding including feelings of anger, gratitude, relief and fear were expressed. Healthcare professionals, carers and patients disagreed on key issues of patient and carer involvement in the decision making process, the quantity of information provided prior to PEG placement, appropriateness of patient selection for the procedure and acceptability of QoL. The delivery of patient centred care must be based on appropriate patient selection, decisionmaking, setting of treatment goals for PEG feeding and the evaluation of the impact of treatment. Current generic QoL measures are highly likely to be inappropriate to measure the impact of feeding upon QoL and a validated PEG specific QoL tool is required to measure the impact of PEG feeding upon QoL. A research proposal has been developed to fully validate the tool for use in clinical practice. The impact of PEG feeding on QoL was variable. Although it is recognised that the results are not generalisable to wider populations, the results support increased patient and carer involvement in the decision-making process, more appropriate information, timely explanations of the procedure and flexible care in the community to meet patients' needs.

Remission is synonymous within cancer care and with other physical disorders, but less known and utilised in relation to people with a diagnosis of schizophrenia. Following work by Andreasen et al (2005) the idea of remission in schizophrenia became more widely utilised as symptomatic remission and was employed as an outcome measure primarily addressing medication efficacy. Whilst remission may or may not be a useful concept, the language, perception and social construction of remission for people with a diagnosis of schizophrenia is also of high importance. To date, there has not been any published material with respect to consultation with service users who have a diagnosis of schizophrenia regarding their personal interpretations and possible concern of the concept of remission. This study explores and conceptualises the possible introduction of the concept of remission into the process of recovery for people with a diagnosis of schizophrenia. Therefore raising the question; “Is remission a useful concept to facilitate transition back into primary care for people with a diagnosis of schizophrenia?”

The National Chlamydia screening programme in England screens only half the number of men compared with women, and the places men are being screened for chlamydia differ from that of women (NCSP, 2012). There is a wealth of data which shows that men are being screened in non-clinical settings, such as educational establishments, or that they are choosing to self-request screening via the internet as opposed to seeking alternative health service provision. However, we are unsure of the reasons for their choice. Furthermore, it is unclear what the impact of a positive or negative diagnosis for chlamydia has on subsequent sexual behaviour. By adopting a situational, qualitative methodology, this study aimed to understand the complex factors involved in men’s sexual health decision making following a request for a home testing kit for chlamydia. The focus for this study was young men aged 20 to 24 years who have a high rate of chlamydia infection, and who have been screened through the National Chlamydia screening programme in the North East of England. Data was collected through ten in-depth interviews, and seven follow up interviews after 12 months. Follow up interviews were primarily used to gauge any long term behaviour change. Patients’ sexual health records provided additional data which was used for triangulation. Data was analysed with the use of framework analysis. Findings from the research were presented to a focus group of professionals and the outcomes from that discussion have been implemented in sexual health provision locally. This research has also fed into a national working group which reviewed chlamydia testing guidelines for positive patients. Findings show that the decisions the young men made about sexual partners and sexual practice are based on a number of factors: pre-influencing factors, which were based on the men’s perceptions and beliefs about women, categorising them as “risky” with a sexually transmitted infection or “clean” with no infections, alcohol use and contraception vs STI prevention . Situational factors including sexual gratification and sexual arousal and post rationalisation factors such as peer pressure and masculinity. Factors influencing decisions to seek testing were triggered by unprotected sex with casual partners, strengthened by catalytic influences including media campaigns. The findings suggest a negative chlamydia test result gives respondents a clean bill of health allowing them to engage in further unprotected sex. A positive diagnosis resulted in the intention to change behaviour and modify sexual practice. After follow up interviews, intention did not lead to actual behaviour change and many became re-infected within 6 months. A conceptual model based on the study findings has been developed for use in professional practice. This model identifies the variables which influence the men’s decision making at different stages in the decision making process. This study has shown that the factors that influence young men’s sexual decision making and the impact of diagnosis on subsequent sexual behaviour have major implications for public health in terms of reinfection and further transmission.

The combination of physical and psychosocial factors observed in cystic fibrosis (CF), has the potential to severely impact on the health related quality of life (HRQoL) experienced by adults with CF. To date, FIRQoL has not been systematically assessed in adults with the disease. This is primarily for two reasons; (a) complete testing and validation of an appropriate generic measure for this population has not been conducted and (b) as yet, no disease specific HRQoL for adults with CF has been developed, tested, validated or published. The present work has addressed both of these deficits by testing and validating a generic measure of HRQoL, the short form 36 (SF-36) item questionnaire, and secondly, by addressing the primary aim of developing, testing and validating a disease specific measure of HRQoL for adults with CF. The research achieved a partial validation of the SF-36 although frill validation proved to be equivocal. Structural validation of the measure using principal components analysis, Cronbach alpha coefficients and correlational techniques indicated that the measure was robust. However, discriminatory sensitivity proved problematic, indicating that across some domains, the SF-36 may not be sensitive to differences based on disease severity. The most original and significant achievement of the work has been the development and validation of a disease specific measure for adults with CF, the cystic fibrosis quality of life (CFQoL) questionnaire. Testing has shown the CFQoL to be structurally robust, reliable, discriminatory and also sensitive to transient changes in health status. Furthermore, using correlational techniques, the work has also highlighted the weak relationships between aspects of HRQoL and clinical indicators. In addition, the information gleaned from the CFQoL during the validation process, identified specific problem areas amongst adults with CF that may be amenable to psychosocial interventions, and which have not previously been targeted in the population. This information would fUrther enhance the multidisciplinary approach to treatment of adults with CF, making interventions truly holistic.

The Maptaphut Industrial Estate is located on the Gulf of Thailand, Rayong Province. The area, which has been designated as a main centre for the petrochemical industry currently occupies 16 sq km and comprises petrochemical plants, chemical and fertilizer plants, refineries, construction plants, and steel industry; there are also residential and commercial areas (IEAT, 2004). There is a significant population around the site, with 24,000 inhabitants in the immediate vicinity according to Jadsri et a/ (2006). The estate has been held responsible for deaths and hospital admissions due to leaks and accidents dating back as far as 1997. Whilst the environmental and health and safety performance of the estate as a whole has significantly improved over recent years, there are still significant outpatient admission rates to Maptaphut hospital for respiratory illness, as recently reported by Jadsri et al. (2006), raising the question of whether local emissions are significantly contributing to ill health, or whether general background concentrations of pollutants from nearby road sources and from Rayong City are the main contributions. The main aim of this research, therefore, was to accurately model the dispersion of pollutants from the estate, and to attempt to quantify the health impacts of these emissions. The specific objectives of this study were to (a) to characterise meteorological conditions in the Maptaphut area; (b) to develop a multiple linear regression statistical model to characterise and predict atmospheric pollutant concentrations in Maptaphut; (c) to investigate the relationship between air pollution and ill health in Maptaphut using a multiple linear regression statistical model; (d) to evaluate the effectiveness of Gaussian and Computational Fluid Dynamics atmospheric dispersion modelling software packages in predicting ground level pollutant concentrations at points around the industrial estate and (e) to use the results of the dispersion modelling studies to assess the contribution of the industrial estate to the overall atmospheric pollutant load in the Maptaphut area, and from published health impact factors, to assess the overall health impact of the estate. The first objective was to characterise the environmental status, trend, and impacts of air pollution during the period 1998 to 2007. The estate is located in the coastal area; thus, the role of the sea-land breeze has a significant role in the dispersion of air pollutants harmfulness. Data collected for the Maptaphut Industrial Estates area, including regional, temporal and spatial considerations included: meteorological data from 100-metres tall meteorological mast; ambient air quality data from three ambient air quality monitoring stations; industrial emissions data; traffic volume on nearby major roads; and outpatient admissions data at the Maptaphut and Rayong hospitals. Comparisons with the ambient air quality in the Bangkok area were made, and the daily and yearly trends in concentrations of the main air pollutants were analysed. Multiple linear regression models correlating pollutant concentrations with respiratory outpatient admissions rates showed that 03, PMio and NO were statistically significant determinants. The overall correlation had a coefficient of Determination (R2) of 41.4% for one week average data, increasing to 51.2% when air temperature and %RH were included. Accumulation effect of pollutants up to four weeks period exposure does not appear to have an effect. A basic health impact analysis study using the ADMS modelled concentrations and the WHO AirQ tool, along with default risk factors, showed that emissions from the Maptaphut industrial estate account for almost all of the NO2 and SO2 related respiratory illness and between 10 and 27% of the PMio related admissions; this actually represents less than 2% of the total respiratory admissions for this area.