This thesis explores the benefits and limitations of traditional evaluations of maternity care, looking specifically at one innovation in service provision, a midwife managed delivery unit. The research undertaken in this thesis can be described in terms of three developmental phases. In phase one, care in a midwife-managed delivery unit is compared with care in a consultant-led labour ward within the framework of a randomised controlled trial. 'Success' is measured in terms of both the clinical aspects of care and as viewed by the women who received this care. Care of women at low obstetric risk in a midwife-managed delivery unit is shown to result in less intervention, greater continuity of carer, more involvement in decision making and greater women's satisfaction with how care was managed. There were no differences in overall satisfaction and the limitations of satisfaction as an outcome measure are discussed. Phases two and three build on the work of the randomised controlled trial. In phase two, perinatal mortality and morbidity data are reviewed through an independent case review of the perinatal deaths and further analysis of the morbidity data. In phase three, the thesis utilises techniques from the discipline of health economics to go beyond the traditional measure of women's views, satisfaction. Willingness to pay and conjoint analysis are used to determine women's preferences, and the strength of these preferences, for different models of maternity service provision.

The structure of the health service in Iran has been described and the role and position of Radiology within the service explained. A comparison has been made between the current basic recommendations and requirement of the IAEA for a radiology service and requirements as laid down in the Iranian legislation. Omissions have been highlighted and suggestions made as to how the Iran legislation could be improved to ensure full compliance. An analysis of the structure of Radiology in Iran has been made and recommendations made as to the improvements which should be made to bring staffing levels and training up to minimum international levels. Measurements of patient and staff doses received during radiology in Iran are reported and from these estimates of potential population dose made. Cost benefit analysis has been undertaken with regard to these doses and recommendations made with regard to the optimum steps that could be taken to reduce patient and staff dose.

It is only when furnished with facts that one can move away from mere opinion towards objectivity, and replace anecdotes with evidence. It was this belief that led Professor I.M. Richardson of the Department of General Practice at Aberdeen University, to take a close interest in the development of accurate observations of the work of various members of the community health team. This interest was first given expression in a study conducted by Dr. I.C. Buchan, who adopted time-study techniques to measure "everything that visibly happened" between patients and their general practitioners (Buchan and Richardson, 1973). This study was so successful in achieving a detailed analysis of professional medical activity, that it seemed logical and desirable to extend the study to the work of the district nurse. So, when I wrote to Professor Richardson expressing an interest in the field of community health research, he approached Mrs. A.M. Taylor, then Divisional Nursing Officer of the Aberdeen District Nursing Association, who showed great interest in the. idea of a study of the nurses' work. A research proposal was drawn up and was approved by the then Research and Intelligence Unit of the Scottish Home and Health Department. The study commenced in April 1972. The nursing study drew upon the methods already successfully employed, and I acknowledge ray debt to Dr. Buchan who undertook the unglaraorous task of adapting time study techniques to the observation of professional activity. However, my own grounding in nursing and the social sciences prompted me to view this opportunity for direct observation of nurses as a valuable means of exploring the nurse-patient relationship. Previous related research experience had highlighted two factors: firstly, there is a dearth of research on nurse-patient interaction in this country, and secondly, a study of such interaction could yield new insight into the nature of nurses' work. Indeed it was felt that this was a crucial adjunct to time study in any thorough description and analysis of district nurses at work. The first task, then, was to determine the extent of the research already carried out in this field. The aim of the following literature review is to examine existing knowledge, to identify areas which have not been thoroughly researched, and to construct hypotheses for the observation study.

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The study presents the thesis that nursing with its wide range of work in spheres of the management, teaching and prac¬ tice of nursing care relies for its maintenance and extension upon the stable contributions of auxiliary workers. Auxiliaries in the U.K. context are nursing workers without recognised qualification to nurse and who may have little or no formal training for their work. A secondary theme is argued that auxiliaries are inherently disadvantaged in the professional nursing structures. The disadvantage is due to a reified image of nursing which is unrelated to patients' needs and unrelated to the daily practice of nursing care. The reification of nursing and the resulting disadvantage to unqualified nursing workers render them less effective than their quantity and human potential should allow. Through the means of two national reviews of policies related to auxiliaries in general and psychiatric divisions of the N.H.3., a wide variety of patterns of employment, instruction, and use were found; nursing managers also revealed a range of problems met in the employment of less-than-fully qualified workers in nursing systems. With this problem-oriented perspec¬ tive, the characteristics and work of auxiliaries in one English health district characterised by relatively low reliance upon these workers, are described. The health district, one of three districts serving as case studies for^he government health department—funded research, was examined by means of postal questionnaires, personal interviews, work diaries and observation of nursing activities. The study, endeavouring to contribute to the discussion of work levels in health care, and within this in nursing care of patients, provides base-line information upon which experimental research may be undertaken.

This study attempts to identify the interplay between the statutory qualifying associations in nursing, the service within which they operate and the climate of opinion in the profession they serve. Using a case study approach one such organisation is chosen as the vehicle far the exploration of the factors influencing the powers and responsibilities of a qualifying association and the significance of its relationship with the central government departments.

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