Non-medical prescribers make an increasing contribution to healthcare across the UK yet little is known about influences on their prescribing decision-making. The aim of this programme of research was to explore and describe prescribing decision-making by non-medical prescribers. A two stage programme of research was carried out. Stage 1 was a systematic review of the social and cognitive influences on prescribing decision-making by non-medical prescribers. Despite a paucity of research, various influences on prescribing decision-making were reported including evidence based guidelines, peer support and patient (or parental) relationships and expectations. While confidence and clinical experience as a practitioner were cited as influences, the lack of prescribing experience and aspects of pharmacological knowledge also impacted on prescribing decision-making, resulting in a cautious approach. Stage 2 of the research employed a phenomenological methodology underpinned by the Theoretical Domains Framework of behavioural determinants (TDF). It comprised three phases. In Phase 1, semi-structured interviews with five nurse prescribers and eight pharmacist prescribers in NHS Grampian explored their experiences and perceptions of influences on their prescribing decision-making, and the impact of these influences. Multiple and sometimes contradictory influences were uncovered. Twelve of the fourteen domains of the TDF were found to be influential along with multi-disciplinary working and experience; optimism and reinforcement did not feature. In Phase 2, these participants recorded reflections on prescribing decisions which they considered noteworthy in relation to their practice, and in Phase 3 participants were interviewed about their reflections. Complexity was a feature of many, in the patients’ clinical or social circumstances or in relation to wider concerns. The same 12 domains were found to be influential as were multi-disciplinary working, experience and complexity. This programme of research has produced original findings which it is hoped will impact on the education, training and practice of these increasingly important prescribers.

This thesis sought to explore the phenomenon of discontinuing neuroleptic medication for psychosis. It comprises three standalone papers. Papers one and two have been prepared for submission to journals and in accordance with the journal guidelines. Paper one is a systematic literature review synthesising studies investigating the association between neuroleptic discontinuation and functional outcomes. Databases were systematically searched and thirteen studies were included in the review. Evidence regarding the association between discontinuation from neuroleptic medication and functional outcomes was mixed. Findings are limited by the scarcity of evidence, diversity in the study methods and designs used, and methodological and design quality issues. Paper two is a qualitative study exploring personal accounts of making choices about neuroleptic medication, specifically considering decisions to discontinue. Twelve participants were interviewed and a constructivist grounded theory approach was used to analyse transcripts. The findings suggest that making sense of choices relates to a continuation-discontinuation spectrum and involves three interrelated tasks. The tasks are: forming a personal theory of the need for, and acceptability of, neuroleptic medication; negotiating the challenges of forming alliances with others; and weaving a safety net to safeguard wellbeing. A theoretical model explaining the processes involved in the tasks and the mediating factors is presented and discussed. The clinical implications of the findings are discussed with reference to existing literature. Paper three is not intended for publication and is a critical review of the research process, in which the strengths and weaknesses of the systematic review and empirical study are evaluated. Personal and professional reflections on the experience of conducting a systematic review and an empirical qualitative study are discussed and the implications of the research for future clinical practice and research are considered.

The recent changes in legislation and codes of practice expand the role of the educational psychologist to a wider age range: 0-25. Moreover, surveys suggest an increasing number of children and young people experience difficulties with mental health, including depression. A systematic literature review of what narratives young people use to communicate depression was undertaken in the first paper. Despite an abundance of literature about depression in clinical settings, only eight studies met the inclusion criteria and were incorporated in the synthesis. A number of issues were identified including ways and methods of communicating depression and the impact of normative pressures and gendered experiences. Findings have implications for practitioners working with young people and have been used to develop a tentative framework for effective practice. The second paper reports on qualitative research, adapting a phenomenological approach. The self-selected participant sample (three university students, aged 19-21) had experiences of living with depression. Each participant was interviewed three times, using focused semi-structured interviews. The data were subsequently transcribed and analysed using a framework of Interpretative Phenomenological Analysis (Smith, Flowers & Larkin, 2009). The themes were grouped into superordinate themes and interpreted in the light of researcher's own experiences and knowledge. Two reported themes 'the weariness of the world was upon me' and 'it all fell down to chance' discuss embodied experiences of living with depression and barriers and facilitators to accessing help, which was mostly coincidental. Finally, the third paper discusses evidence-based practice, ways of achieving impact in research, and dissemination of research at individual, organisational and academic level. Overall, the present research suggests that educational psychologists can play an important role in raising awareness of children and young people living with depression, as well as promoting mental health, wellbeing and resilience in a variety of educational settings and amongst practitioners working with children and young people.

Care home admission following acute hospitalisation is a lived reality across Scotland, experienced by over 8,000 people annually. The aim of this thesis was to develop an understanding of new care home admission following acute hospitalisation. Methods and findings from the mixed-methods approach are presented in three parts. Part One: Identifying relevant research - includes a review of quality assessment tools for systematic reviewing; a systematic review and meta-analysis of quantitative data from observational studies of predictors of care home admission from hospital; and a methodological chapter on developing a search filter to improve accessibility of existing research findings supported by the findings of an international survey of care home researchers. The systematic review identified 53 relevant studies from 16 countries comprising a total population of 1,457,881 participants. Quantitative synthesis of the results from 11 of the studies found that increased age (OR 1.02 per year increase; 95%CI 1.00-1.04), female sex (OR 1.41; 95%CI 1.03-1.92), dementia & cognitive impairment (OR 2.14; 95%CI 1.24-3.70) and functional dependency (OR 2.06; 95%CI 1.58-2.69) were all associated with an increased risk of care home admission after hospitalisation. Despite international variation in service provision, only two studies described the model of care provided in the care home setting. The survey identified that there is a lack of shared terminology in the published literature to describe settings for adults who are unable to live independently in their own homes and require care in a long-term institutional setting. A search filter to identify relevant research could help to overcome differences in terminology and improve synthesis of existing research evidence. Part Two: Exploring current clinical practice - reports the findings of a retrospective cohort study of new care home admissions from hospital using case-note review methodology accompanied by findings from inductive thematic analysis of a single dataset from a qualitative case study design exploring the experiences of a patient, their family, and practitioners (n=5). The cohort study (n=100) found a heterogeneous picture with long hospital admissions (range 14-231 days), frequent transfers of care (31% experienced three or more transfers), varied levels of documented assessment and a lack of documented patient involvement in the decision-making processes. The qualitative interviews allowed the patient voice to emerge, alongside the professional and family narrative which dominated case-note documentation. Inductive thematic analysis identified nine major themes exploring how decisions are made to discharge individuals directly into a care home from the acute hospital setting: biography & personality; professional role; family role; limitations in local model of care; ownership of decision; risk; realising preferences; uncertainty of care home admission process; and psychological impact of in-hospital care. Part Three: Harnessing routinely-collected data - includes the challenges of identifying care home residency at admission and discharge from hospital, presenting analysis of the accuracy of Scottish Morbidity Record 1 (SMR01) coding in NHS Fife and the Community Health Index (CHI) Institution Flag in NHS Fife and NHS Tayside. This is followed by a descriptive analysis of the Scottish Care Home Census (2013-16) as a novel social care data source to explore care home admissions from hospital and the methodology for a data linkage study using these data. Identifying care home residents in routine data sources is challenging. In 18,720 admissions to NHS Fife, SMR01 coding had a sensitivity of 86.0% and positive predictive value of 85.8% in identifying care home residents on admission. At discharge the sensitivity was 87.0% and positive predictive value was 84.5%. From a sample of 10,000 records, the CHI Institution Flag had a sensitivity of 58.6% in NHS Fife and 89.3% in NHS Tayside, with positive predictive values of 99.7% and 97.7% respectively. From 2013-16, of 21,368 admissions to care homes in Scotland, 56.7% were admitted from hospital. There was significant regional variation in rates of care home admission from hospital (35.9-64.7%) and proportion of Local Authority funded places provided to admissions from hospital (34.4-73.9%). Those admitted from hospital appeared to be more dependent and sicker than those admitted from home. This thesis has established a series of challenges in how care homes and their residents are identified. It has questioned the adequacy of the evidence to guide practitioners and sought to raise the profile of this vulnerable and complex population and how best to support them in making decisions regarding admission from the acute hospital. It has progressed our understanding of this under-explored area and proposes a programme of future mixed-methods research involving patients, families, practitioners and policy-makers.

Background Dementia has been a global priority for over a decade, with a recognition that it presents a growing challenge for all those directly affected, as well as for health and social care services. For those who are caring for a relative at home, carer burden has been found to be predictive of physical and mental health problems, and can impact on the decision to place a relative in fulltime residential care. Gaining a fuller understanding of factors that impact on caregiver burden may help inform the development of effective interventions for this population. This thesis comprises a systematic review of the literature on individual behavioural and psychological symptoms of dementia (BPSD) and their impact on carer burden, a cross-sectional study of one hundred and ten dementia caregivers, exploring the impact of executive functioning deficits, and potential mediating mechanisms, on carer burden and positive gain, and a development and feasibility study of an Acceptance and Commitment Therapy (ACT) group intervention for dementia caregivers. Systematic Review Twenty-one studies measured the association between at least one individual symptom, or symptom cluster, and carer burden, and are included in the review. All studies found at least one symptom to be significantly associated with burden. However, due to the heterogeneity of studies in this field, there was insufficient evidence to establish whether any symptoms are more closely associated than others. Issues regarding the conceptualisation of burden and measurement of BPSD are highlighted and suggestions for addressing this in future studies proposed. Method One hundred and ten dementia caregivers completed five self-report questionnaires as part of a cross-sectional design, aiming to explore the role of executive functioning deficits, dementia management strategies and experiential avoidance in 2 the development of carer burden and positive gain. Drawing on these findings, a group intervention, based on ACT, was developed and delivered to twenty-three dementia caregivers. Data on attendance, attrition and qualitative feedback was collected as an indication of acceptability, and a quasi-experimental design, involving four pre, post and follow-up measures was employed to provide preliminary data on effectiveness. The measures used in both studies were the Dysexecutive Questionnaire (DEX) (study 1 only), Zarit Burden Interview (ZBI), Positive Aspects of Caregiving Questionnaire (PAC), Dementia Management Strategies Scale (DMSS) and Experiential Avoidance in Caregiving Questionnaire (EACQ). Results & Conclusions In study one, executive functioning deficits were found to account for most variance in burden. The use of negative management strategies and Active Avoidant Behaviour (a subscale of the EACQ), were also associated with higher levels of burden, while positive management strategies were associated with positive gain. The results suggest that management strategies and experiential avoidance could be potential mediating mechanisms in the development of carer burden, and so were targeted in the ACT group intervention in study two. Findings from study two indicate that the group intervention was feasible and acceptable to caregivers, with subjective change reported in understanding of behavioural changes in the care-recipient, ability to handle negative emotions and valued living. Suggestions are made regarding alternative outcome measures for future studies in order to capture participants’ experience more fully, as there was little statistically significant change in this study. Suggestions are also made regarding future directions for the intervention.

Vertebrados exóticos são introduzidos intencionalmente como recurso, como uma alternativa para fins econômicos ou de lazer. Aqueles que se tornam capazes de expandir espontaneamente as novas populações em áreas naturais são conhecidas como invasores e frequentemente estão implicados em efeitos indesejados em populações, comunidades e ecossistemas autóctones. Uma destas espécies é o cervo axis Axis axis, introduzido mundialmente para a caça. Apesar da sua ampla distribuição e utilização, pouco se sabe sobre seus efeitos nas áreas invadidas e em quais regiões esta espécie pode se tornar invasora. Isto dificulta as tomadas de decisão, pois avaliar os efeitos da introdução e prever as áreas em risco de invasão são tarefas fundamentais para estratégias de prevenção, priorização e ações de controle. Assim, esse trabalho teve como objetivos revisar os efeitos do cervo axis em áreas invadidas, utilizando um protocolo de revisão sistemática, e modelar a possível distribuição mundial e regional desta espécie, utilizando variáveis bioclimáticas. Realizamos buscas por estudos sobre efeitos em áreas alóctones em três bancos de dados, utilizando três conjuntos de palavras chaves. Classificamos os estudos que atenderam aos critérios do protocolo segundo o nível de inferência sobre os efeitos em Efeito Demonstrado e Efeito Sugerido. Extraímos os tipos de efeitos relatados e a região de ocorrência. Para a modelagem de distribuição, utilizamos o algoritmo Maxent e variáveis preditoras bioclimáticas. Os pontos de ocorrência utilizados incluem sua distribuição original e três regiões onde a espécie é invasora e das quais foi possível obter ou estimar coordenadas. A revisão sistemática resultou em apenas quatro trabalhos classificados em Efeito Demonstrado, os quais apontam a competição com espécies nativas, alteração da composição florística e faunística e facilitação da entrada de outras espécies invasoras. Os efeitos sugeridos incluem seis trabalhos mostrando a ocorrência de parasitas, um caso de hibridização com outra espécie de cervídeo em cativeiro e um estudo mostrando a degradação das áreas de florestas causada pelo cervo axis em conjunto com outras espécies invasoras. O modelo de distribuição demonstra que amplas extensões da América do Sul, África Central e Sudeste Asiático são suscetíveis à invasão, portanto, nestas áreas deve-se evitar a introdução e controlar a expansão. O sul do Brasil, Uruguai, norte da Argentina e Paraguai são possíveis áreas de ocorrência segundo os modelos bioclimáticos. / Alien vertebrates are intentionally introduced for leisure and economic purposes. Those who become able to expand their populations in the new areas are known as invasive and are often involved in undesirable effects in indigenous populations, communities and ecosystems. The axis deer was introduced worldwide for hunting. Despite its wide distribution and use, little is known about its effects on the invaded areas and regions in which this species can become invasive. This complicates the decision-making because assessing the effects of the introduction and predict areas at risk of invasion are key tasks for prevention strategies, prioritization and control actions. Like this. So, this study aimed to summarize the effects of the axis deer in invaded areas using a systematic review protocol and to model the potential distribution of this species globally and in South America using bioclimatic variables. To summarized the effects we conducted searches for studies on non-native areas in three databases, using three sets of key-words and classified the studies that met the criteria of the protocol according to the level of inference about the effects they investigated. We extracted the types mentioned effects and occurrence region. To model the potential distribution based on bioclimatic variables we used the program Maxent. We used occurrences from the original distribution and three regions where the species is invasive about which geographical coordinates could be obtained or estimated. Four studies demonstrated effects of the axis deer due to competition with native species, changes in the floristic and faunistic composition and facilitation of other invasion processes. Six studies speculated the occurrence of disease transmition, hybridization with other species and difuse degradation of forest areas in combination with other invasive species. The distribution model demonstrated that large extensions of South America, Central Africa and Southeast Asia are susceptible to invasion. In the southern cone of South America Brazil, Uruguay, northern Argentina and Paraguay include extensive areas prone to invasion based on the bioclamatic models.

Orientadores: Egberto Ribeiro Turato, Fernanda Garanhani de Castro Surita / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-10-24T19:02:39Z (GMT). No. of bitstreams: 1 Schutzer_DeboraBicudodeFaria_M.pdf: 2323591 bytes, checksum: 5c70bf4582f7b4d7a88f7b78e7704dd0 (MD5) Previous issue date: 2014 / Resumo: Objetivo: Compreender as vivências emocionais relatadas por gestantes obesas que tiveram variação adequada de peso durante o acompanhamento pré-natal no Ambulatório de Pré-Natal Especializado do CAISM/UNICAMP. Métodos: Para contextualização e compreensão do objeto de estudo, realizou-se uma revisão sistemática de literatura em bases de dados. Foram acessadas bases de dados e contempladas publicações entre janeiro/2003 até junho/2013, que abordavam diretamente aspectos psicológicos na intervenção ou vivência da gestante obesa. Foram incluídos 08 artigos nessa revisão, 03 de metodologia qualitativa e 05 de metodologia quantitativa. Para a pesquisa de campo foi utilizado o desenho clínico-qualitativo. A amostra de sujeitos foi intencional e concluída pelo critério de saturação de informações com 13 mulheres Utilizou-se a técnica de entrevista semidirigida de questões abertas. A técnica de tratamento de dados incluiu: transcrição na íntegra das entrevistas, releituras flutuantes para desvelar núcleos de sentidos das falas das entrevistadas, categorização em tópicos para discussão e análise qualitativa de conteúdo. Cuidados éticos foram tomados seguindo as normas preconizadas pelo Conselho Nacional de Saúde. Resultados: A revisão sistemática indica que aspectos emocionais como depressão, ansiedade e stress estão associados ao IMC na gestação; sendo que quanto maior o IMC, maiores os índices dos aspectos psicológicos referidos. Os estudos qualitativos revisados indicam que a experiência da mulher obesa quando gestante envolve sentimentos em relação ao estigma da obesidade, o julgamento, sentimentos de humilhação e críticas aos profissionais de saúde quanto aos preconceitos e falta de suporte à mulher nessa situação. Da análise dos dados qualitativos emergiram quatro categorias. Sendo que três delas mostram um caminho de cuidado com o corpo que as mulheres obesas percorreram durante a gestação: 1) O corpo começa a ser pensado; 2) O desafio da dieta; 3) A relação com a equipe de saúde pré-natal. E a quarta categoria que revela uma origem da motivação para a mudança: 4) O potencializador das mudanças. Conclusão: A revisão sistemática de literatura indica que há um numero relativamente pequeno de estudos que consideram os aspectos psicológicos na gestação de uma mulher obesa. Existe uma demanda psicológica destas de que a equipe de cuidado pré-natal as vejam para além dos estigmas da obesidade e das questões gestacionais. A pesquisa de campo aponta que a gestação é um momento oportuno para a mulher entrar em maior contato consigo mesma e notar seus conflitos emocionais. Através das transformações no corpo, a mulher pode iniciar um processo mais refinado de autocuidado e vivência da unidade corpo-mente. O medo da própria morte ou do bebê, ocasionados pelos riscos que a obesidade oferece, demonstrou ser um grande potencializador de mudanças. A relação com os profissionais da equipe de saúde exerce um papel importante no suporte motivacional à gestante obesa / Abstract: Objective: To understand the emotional experiences reported by obese pregnant women that had adequate variation in weight during the pre-natal follow-up at the PreNatal Care Outpatiet Clinic of the CAISM/UNICAMP. Methods: For understanding and contextualization of the object of study, a systematic review of the current literature was firstly done on databases about the subject obesity in pregnancy in its psychological aspects. For the systematic review in literature, databases and covered publications between January/2003 to June/2013 were accessed, which approached directly psychological aspects in the intervention or experiences of obese pregnant women. Eight articles were included in this review, 03 regarding qualitative methodology and 05 quantitative methodology. For the field survey, the Clinical Qualitative Method was used. The sample of subjects was intentional and completed by the criterion of information saturation with 13 women, the technique of interview with open questions was used. The interviews were conducted individually in the Prenatal Care outpatient clinic of the CAISM/Unicamp. The technique of data included: full transcript of the interviews, floating rereading to unveil cores of meanings from interviewees' discourse, categorization in topics for discussion and qualitative analysis of content. Ethical Care was taken following the standards recommended by the National Health Council. Results: The systematic review indicates that emotional aspects such as depression, anxiety and stress are associated with body mass index in pregnancy; being that the higher the BMI, the higher the rates of referred psychological aspects. The qualitative studies reviewed indicate that the experience of obese women when pregnant involves feelings in relation to the stigma of obesity, judgement, feelings of humiliation and criticism to the health professionals as to the prejudices and lack of support for women in this situation. The analysis of the qualitative data in this research emerged from four categories. Three of them show a path of caution with the body that obese women have taken during the pregnancy: 1) The body begins to be heavy; 2) The challenge of the diet; 3) The relationship with the prenatal health team; and the fourth category that reveals a source of motivation for changing: 4) Changes enhancer. Conclusion: The pregnancy is an opportune moment for women to come into greater contact with themselves and to notice their emotional conflicts. Through the changes in the body, the woman can start a more refined process of self-care and the experience of body-mind unit. The fear of death itself or the baby's, caused by risks that obesity offers, proved to be a great enhancer effect of changes. The relationship with the professional health team plays an important role in motivational support to pregnant obese women / Mestrado / Saúde Materna e Perinatal / Mestra em Ciências da Saúde

This thesis focuses on psychosocial interventions for psychosis. It consists of two parts: a systematic review on quality of life in forensic settings and an empirical study on negative symptoms. The systematic review follows the publication guidelines of the journal International Journal of Forensic Mental Health whilst the empirical study follows the publication guidelines of the journal Clinical Psychology and Psychotherapy. Reasonable adjustments have been made to the formatting of this thesis to enhance readability. Purpose: The systematic literature review aimed to summarise and critically appraise studies that have evaluated the effects of psychosocial interventions for psychotic disorders in forensic settings on quality of life. The empirical study aimed to evaluate the feasibility of Metacognitive Training (MCT) for negative symptoms and to identify mechanisms of change. Methods: The literature was systematically searched (using four databases) for research that included any quantitative measure of quality of life (i.e. self-esteem, quality of life, life satisfaction, and/or self-efficacy in relation to life-goals). In the empirical study, a new intervention was developed by modifying MCT for negative symptoms and four aspects of feasibility were evaluated: acceptability, practicality, demand and limited efficacy. The quantitative approach was supplemented with qualitative interviews on participants' views of the intervention. In addition, potential mechanisms of change were evaluated using a promising new method for analysing data from case-series: multilevel modeling. Results: In total, 10 papers met the inclusion criteria in the systematic review. Significant improvements in quality of life were found in five studies. The modified version of MCT showed good feasibility as demonstrated by the attendance rate, the positive oral feedback from participants and the multidisciplinary team, and the improvements on negative symptoms that were found following the intervention. Multilevel modeling proved useful in explaining the variance attributable to three different predictors: depression, internalised stigma, and reflective functioning. Conclusions: It was found that quality of life can be improved in forensic settings using psychosocial interventions. The pilot study indicated that MCT for negative symptoms has high feasibility and that changes in negative symptoms can partially be explained by depression, stigma, and reflective functioning.

Background: Parents of children with epilepsy have been shown to have higher rates of depression, anxiety and stress in comparison to parents of children without epilepsy due to the impact of caring for a child with a chronic condition. A systematic review of existing literature aimed to identify qualitative research that examined parents' experiences of caring for their children with epilepsy. Methods: The systematic review explored the experiences that parents have in caring for their child with epilepsy. A search of electronic databases for qualitative literature was completed. The quality of all eligible articles papers was assessed, and findings from studies were synthesised. Results: Twelve studies met inclusion criteria for the review; findings suggest that parents need time to process their child's diagnosis of epilepsy; they cope with this in differing ways and are motivated to learn how to adapt and cope with parenting their child with epilepsy. Conclusions: Parents of children with epilepsy may experience symptoms of stress, this may motivate them to learn how best to care for their child. Empirical Paper Abstract Background: Parents' experiences of being told about sudden unexpected death in epilepsy (SUDEP) may be particularly challenging to cope with. As little is known about how mothers understand and make sense of SUDEP, a qualitative research project aimed to explore mothers' experiences. It was hoped this would be helpful for clinicians to understand in order to assist them in providing information to parents in a way that minimises distress. Methods: The empirical article explored mother's experiences of being told about SUDEP and the subsequent impact of this for 11 mothers of children with epilepsy. Interpretative Phenomenological Analysis methodology was utilised, with themes derived from interpretation of interview transcripts, in order to describe the experiences of the participants. Results: Within the empirical study, five themes emerged. The way in which mothers found out about SUDEP seemed to have a link to their perception of risk and how they subsequently managed feelings of uncertainty and the psychological impact of knowing about SUDEP. Mothers' recommendations to clinicians included when, how and what to tell other parents, and were based on their own helpful and unhelpful experiences of being informed about SUDEP. Conclusions: In being told about SUDEP, mothers may struggle to make sense of it and this can be associated with an increase in anxiety. However, clinicians can reduce potential distress by carefully timing when and how they tell parents, and by making sure information is clear and relevant for the child in question.

The thesis begins with an exploration of my experiences of caring for dying babies which considers the way in which the care given to dying babies differs according to the care environment. This sets the scene for an exploration of rituals surrounding their care. Critical Interpretive Synthesis was selected as a research design for the study because it offered the opportunity to take an interpretive approach to a range of data and allowed the creation of new arguments. Documentary data including professional literature, professional textbooks and professional guidelines were analysed and interpreted using methods which guideline analysis, critical appraisal and rhetorical analysis. The diverse range of analyses facilitated both the rigour and meaning of the data to interrogated. Performance Theory was used as the theoretical framework in the thesis to allow the rituals to be revealed and explored as dramatic performances. The thesis demonstrated that the origin of the rituals was rooted in the need for the baby to be treated with compassion and dignity and to provide parents with the opportunity to form meaningful attachments in the brief period between the previable baby’s birth and death. The rituals were devised by parents who had been bereaved and were incorporated into guidelines. The guidelines practised the rhetoric of choice but the data demonstrated that the rituals appear to have been adopted as routines which were then used indiscriminately, robbing them of their meaning.The findings reveal how care to meet the physical needs of the dying previable baby requires to be made more explicit to enable the ideology and of ‘comfort care’ to be realised in practice. The thesis also demonstrated a need for inclusiveness to represent the spectrum of parents affected by the death of a previable baby when researching perinatal loss and formulating policy.