Introduction: My ten published papers focus on two domains of the quality agenda, patient safety and patient experience, concentrating on how quality improvement can reduce the occurrence of serious consequences of patient harm and poor patient experience. Aims: My goal was to design, test and discover how to make improvements in clinical practice in four areas: sleep deprivation, infection prevention, falls prevention and pressure ulcer prevention. Literature Review: There was limited evidence of successful strategies for change to improve quality. Common quality improvement challenges were within the complex critical care environment and an urgency to act without the focus on well-designed methods. Design and Methodology: A broad range of research methods was applied to evaluate the implementation of improvement interventions in critical care. These included: observational designs to uncover understanding on patient experience, activities and processes; before and after design; stepped cluster design and longitudinal time series design, utilised to increase confidence with attributable effect from the interventions. Results: My appraisal of my ten publications showed quality varied. Process and outcome measures were used to determine the success, and I received national and local recognition for some of my work. Discussion My three main knowledge contributions were: · practical ways to help nurses assess and improve patients’ sleep · risk assessment approaches · translation and implementation of improvement methodology in critical care. I discovered four cross-cutting themes which add to quality improvement knowledge and I developed an enhanced model for improvement. The four themes are: · clinical leadership at a programme and local level · using a bundle of technical and non-technical interventions · undertaking patient risk assessment to guide interventions · the value of data measurement and feedback Conclusions & Recommendations: My work has improved patient experience and patient safety knowledge. With further testing this knowledge could greatly benefit other areas of healthcare.

In line with technological developments, there is almost no limit to collect data of high dimension in various fields including bioinformatics. In most cases, these high dimensional datasets contain many irrelevant or noisy features which need to be filtered out to find a small but biologically meaningful set of attributes. Although there have been various attempts to select predictive feature sets from high dimensional data in classification and clustering, there have only been limited attempts to do this for regression problems. Since supervised feature selection methods tend to identify noisy features in addition to discriminative variables, unsupervised feature selection methods (USFSMs) are generally regarded as more unbiased approaches. The aim of this thesis is, therefore, to provide (i) a comprehensive overview of feature selection methods for regression problems where feature selection methods are shown along with their types, references, sources, and code repositories (ii) a taxonomy of feature selection methods for regression problems to assist researchers to select appropriate feature selection methods for their research (iii) a deep learning based unsupervised feature selection framework, DFSFR (iv) a K-means based unsupervised feature selection method, KBFS. To the best of our knowledge, DFSFR is the first deep learning based method to be designed particularly for regression tasks. In addition, a hybrid USFSM, DKBFS, is proposed which combines KBFS and DFSFR to select discriminative features from very high dimensional data. The proposed frameworks are compared with the state-of-the-art USFSMs, including Multi Cluster Feature Selection (MCFS), Embedded Unsupervised Feature Selection (EUFS), Infinite Feature Selection (InFS), Spectral Regression Feature Selection (SPFS), Laplacian Score Feature Selection (LapFS), and Term Variance Feature Selection (TV) along with the entire feature sets as well as the methods used in previous studies. To evaluate the effectiveness of proposed methods, four different case studies are considered: (i) a low dimensional RV144 vaccine dataset; (ii) three different high dimensional peptide binding affinity datasets; (iii) a very high dimensional GSE44763 dataset; (iv) a very high dimensional GSE40279 dataset. Experimental results from these data sets are used to validate the effectiveness of the proposed methods. Compared to state-of-the-art feature selection methods, the proposed methods achieve improvements in prediction accuracy of as much as 9% for the RV144 Vaccine dataset, 75% for the peptide binding affinity datasets, 3% for the GSE44763 dataset, and 55% for the GSE40279 dataset.

Lignocellulose is the major component of the plant cell wall and is a sustainable source of inexpensive abundant biomass. Efficient degradation of the lignocellulosic polysaccharides, cellulose and hemicellulose, is required if the plant cell wall is to be used as a resource for renewable biofuels. Microorganisms have the ability to catalyse the degradation of such bio-material through a cascade of enzyme activities into fermentable sugars and therefore are considered to be a major resource of biocatalysts for the emerging biofuel industry. The stability of the component polysaccharides and the complexity of the plant cell wall are reflected in the diverse range of functions and substrate specificities of lignocellulosic degrading enzymes. Part of this work describes the identification of a novel GH8 endo-xylanase, OtXyn8A, from the soil bacterium, Opitutus terrae. GH8 is a family in which there is only a limited amount of data available on the xylanase substrate specificity in comparison to families GH10 and GH11 in which xylanases are well established. With this in mind, OtXyn8A is the only endo-xylanase characterised from GH8 that primarily releases xylobiose from its substrates. Synergy between O. terrae enzymes was partially investigated within this study with the identification of a gene cluster within the bacterial genome. Genes organised within this cluster encoded products required for the degradation of xylan substrates and so the associated enzymes were cloned, expressed and subsequently determined for activity. Combined activities of gene products from the cluster exhibited synergy in the hydrolysis of 4-O-methyl glucuronoxylan. While surveying the genome of O. terrae, the multiplication of genes encoding GH43 enzymes was also investigated. Genes encoding GH43 enzymes were cloned, expressed and investigated for catalytic activity. Three arabinofuranosidases from O. terrae and one from Lactobacillus brevis were characterised, including the characterisation of an exo-1,5-L-arabinofuranosidase. Furthermore, a β-xylosidase from O. terrae was characterised which exhibited dual functionality as it catalysed the release of arabinose in addition to xylose from arabino-xylooligosaccharides.

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Advances in health care have led to an increasing emphasis on family involvement in the day-to-day care of children with chronic renal disease, but if families do not become competent in this it can negatively influence the child's management. Research into the psychosocial implications of childhood chronic disease has been prolific in recent years, although relatively few studies have investigated the way that families learn about chronic disease management. However, a body of work is emerging in the human sciences around the premise that social engagement in communities of practice is a fundamental process by which people learn. Building on these lines of research this study, therefore, aimed to explore the way that children with chronic renal disease and their families learned to manage the condition, and to determine the impact of relationships between families and professionals on the learning process. Using grounded theory within a symbolic interactionist approach, data were collected and analysed in two phases (retrospective and prospective). Phase one aimed to uncover the issues that eight children and/or their parents identified as important in learning about the condition since diagnosis in the preceding four years. In phase two, a longitudinal approach (building on phase one analysis) involving six families and key professionals, allowed detailed exploration, over eighteen months, of learning events that arose following referral to a Children's Kidney Unit. A focus on learning by families as social participation in care was identified in the study. A novel, substantive theory, the social theory of learning in childhood chronic renal disease is proposed comprising three categories: the processes of assessing; interacting and synthesising. Assessing is the process by which families and professionals learn through assessing the disease course as well as each others' ability and social positioning. Interacting is the process whereby families and professionals learn through sharing knowledge, earning and maintaining trust and engaging jointly in decision making. Synthesising is the process whereby families' and professionals' learn through a new, shared understanding based on knowledge of each others' communities of practice, cultures and patterns of learning. The theory conceptualises family learning as: a two way process of interaction in developing an ongoing practice between family members and professionals; the influence of interpersonal as well as intrapersonal learning; and not only acquisition of skills but also the formation of identities in the context where the skills are learned. Three patterns of learning also emerged from the data (parallel, integrated and synthesised). These help to explain some of the differences and similarities between families' learning as they move through the chronic disease journey. This study develops and modifies Wenger's (1998) social theory of learning and Gibson's concept of participatory competence (1995) and contributes an innovative perspective to the growing body of knowledge around childhood chronic disease. Testing and further development of the theory and its use in child health is indicated.

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: 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.

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?”