Background. There is an increasing evidence base concerning the need for effective and timely postnatal care to prevent physical and physiological maternal and infant morbidity, but there is little evidence of women's experiences of postnatal care or their views of their recovery after birth. The ethnographic study presented in this thesis sought to increase our understanding of the role of postnatal care and birth recovery over time through the experiences and voices of mothers. Method. The study was located in the neighbourhoods of Salford and Trafford in the North West of England. A period of participant observation in two maternity units using a continuum-based approach was undertaken to explore the influence of the context and environment of postnatal care on women's immediate recovery from birth. This was followed by in-depth conversational interviews with 17 women (three interviews were conducted with each woman) during the first seven months following birth. Findings. Analysis of observational and interview data revealed that initially the impact of power of place of birth impinged upon the celebration of birth as the atmosphere of the postnatal wards with their established rules and care ethos sought to confine women in an unhelpful way. The ward experience revealed contested views between the women and the staff in terms of needs and wants. Thus the promotion of choice and individualised care relied more on chance rather than a formal process of care available for all women. During the provision of formal care giving, constructs of 'normal' were attached to women as midwives searched to manage the occupants of the wards (mothers and babies) and engaged in body regulation processes as a means to judge adaptation to motherhood and recovery. Over time notions of 'self care' prevailed in that women learnt how to manage and cope with their own recovery from birth and adaptation to motherhood. The health and wellbeing outcomes that mattered to the women were centred upon the ways in which they interpreted motherhood and claimed back the self. Conclusions. This study reveals that the current planning and content of routine provision of postnatal care in hospital requires urgent revision. Women's expectations of their health and wellbeing and their needs in the early weeks and months after giving birth, differ from those understood by professionals who continue to adhere to a traditional and ritualistic provision of care. Midwifery needs to re-examine its role in postnatal care, take account of what women say and consider new ways of addressing care after birth.

Myoelectric hand prostheses are controlled via electromyographic (EMG) signals measured at the residual forearm musculature. Active functional use requires control of force and motion of the prosthetic hand in the absence of proprioceptive and tactile feedback from the hand. Many amputees often choose not to use their prosthesis in this way in everyday life. Current clinical tools provide little insight into why this is, and the few studies of motor control strategies and motor learning provide only a very partial explanation. Further studies are therefore required to inform the development of new prostheses and improved training protocols. Moreover, despite the general agreement that amputees compensate for missing proprioception through vision, at the start of the PhD there were no studies of gaze behaviour in upper limb amputees. The aims of the thesis were to: 1. To identify visuomotor behaviours that change over learning to use a myoelectric prosthesis and; 2. To identify the visuomotor behaviours of established users of myoelectric prostheses and their relationships with results from validated clinical evaluation tools. To allow investigation of visuomotor behaviours, an everyday task was chosen, namely reaching for and acquiring a carton, then pouring water from it into a glass. A novel coding scheme for objective analysis of gaze data during task performance was developed and validated. Additionally, methods for describing upper limb kinematics were implemented. Using these tools a study of learning to use a myoelectric prosthesis simulator in anatomically intact subjects revealed a number of variables whose values change dramatically with the introduction of the prosthesis and remain different from baseline, even after practice. For example, subjects remained slower at reaching and more variable in their movement and gaze behaviour. Additionally, subjects had to pay considerable attention to the immediate task requirements. The latter findings may be interpreted as showing that prosthesis use may be attentionally demanding. A second study was then carried out involving established trans-radial myoelectric prosthesis users. Similar behaviours to those reported in the first study (following only a very brief period of practice) were observed, giving insight into why current prostheses remain difficult to use in everyday life; amputees had to pay a high degree of visual attention to the immediate requirements of the task, thus limiting their ability to plan subsequent actions of the task. Additionally, subjects who performed well on the task, were also found to perform well on the clinical evaluation tools.

A stroke can impair both motor and cognitive functioning, reducing the automaticity of walking and increasing susceptibility to motor-cognitive interference (MCI). There is also some evidence of an association between susceptibility to MCI and the increased incidence of falls in stroke. Functional Electrical Stimulation (FES) is commonly used for correction of foot drop due to stroke. At the start of the PhD, studies had shown FES increases walking speed. However, questionnaire-based studies found that users rated a reduction in effort and a reduced risk of tripping or falling as the two most important reasons for using FES. In these studies, the term ‘effort’ was not defined, but the results from a qualitative study suggested that the questionnaire respondents may have been referring to both physical and mental components. Based on this evidence the following research question was posed “Does FES reduce motor-cognitive interference during gait in people with foot drop following stroke?” The question was first examined in a questionnaire study which collated FES user opinion from thirty current users. Respondents identified a statistically significant reduction in concentration required when walking with FES compared with walking without the device. Furthermore, the majority noted that walking without thinking about walking was easier with FES. The second study developed and piloted a dual-task based methodology to assess the impact of FES on MCI during gait. Two participants with foot drop following stroke were evaluated over 14 weeks following first use of FES. In one participant, cognitive task performance was maintained at a similar level when walking with FES, compared with seated performance, and reduced without FES. The effects were less clear in the second participant. However, the study demonstrated the feasibility of the proposed methodology and provided the first quantitative evidence that FES can reduce MCI during gait. In the final study of the thesis, a similar methodology was used to study the effects of MCI in a larger cohort of sixteen established FES users. Outcomes suggest that although FES can reduce the motor-cognitive interference experienced during a dual-task situation in some participants, when analysed as a group, the results did not support the existence of this effect.

This thesis seeks to explore, identify and describe the information needs and the preferences and priorities for information of chronic kidney disease (CKD) patients. The premise of the research being that CKD patients will have preferred key information needs, which are of a priority to them, at different times during the progression of their disease. Attention will focus on three areas: • The theory and methodology underpinning information need research in health and information science, exploring key concepts to establish working definitions • What information patients’ want and the contextual factors that influence the manifestation of an information need • The development and testing of a CKD Information Needs Questionnaire (INQ) that profiles and prioritises information topics to facilitate, demographic and disease progression sub-group analysis Chapters one and two, set the scene and focus of the study, identifying the context of CKD, aetiology, prevalence, current NHS policy and service provision building a clear study rationale. The national political agenda advocates the need to develop patient-led services alongside encouraging self-management skills for CKD patients to meet the future demands on renal services. For this to be achieved understanding the information needs of CKD patients is important. Chapters three to six, consider the theory and methodology underpinning existing research in the field of information need, drawing on expertise from both Information Science and Health. The meaning of information and information need are explored and the contextual factors that influence the need for information extrapolated. Existing evidence on information topics important to CKD patients are drawn from a systematic literature review. The study adopts a mixed method approach combining qualitative in-depth semi-structured interviews and a paired comparison INQ to identify, understand and measure information need. The study findings are presented sequentially in chapter’s seven to nine. The first two chapters scrutinise the qualitative data to elicit core information needs and explore the context in which information needs arise. Information topics from the literature are compared and contrasted with data extracted from the in-depth interviews and nine core information needs identified. These include information on what is CKD and what to expect in the future; physical affect and symptoms of CKD; complications and side effects; different treatment options, practical aspects of treatment; self-management information regarding diet, fluids, medication and blood results; impact of CKD on daily life and social activities; information on how to cope and adapt with CKD and information from other patients about their experiences. Findings indicate that CKD patients have preferences for information that emerge to satisfy an underlying goal. Information needs are hierarchical in nature and influenced by the context of the individual, factors include the relevance of topic, personal circumstances, coping styles, current events and lifestyle. The core information needs were used to ground the development of the INQ, followed by the testing of the tool and subsequent statistical analysis, in chapter nine. The information topics considered highest priority are concerned with information about self-management, complications and physical symptoms. Middle range items included information regarding practical aspects of RRT, how it affects daily life, the cause of CKD, treatment options. Information topics considered less important were how to cope and adapt to life with CKD and information from other patients about their experiences. Differences between information priorities were observed across demographic groups influenced by age, treatment modality and time since diagnosis. Chapter ten draws together the evidence and discusses the findings in context with the wider literature highlighting the strengths and weaknesses of the research strategy. An innovative patient-led information strategy is proposed based on the construction of meaning and making sense of information, alongside practical changes to improve the quality of information provision to meet the needs of CKD patients. Chapter eleven concludes the study and denotes recommendations for future information need research, information provision in practice and policy. These include the application of the nine core information needs (as a topic guide) in clinical practice to initiate patient discussion and draw out specific individual information need. The evidence base developed from this in-depth study will inform and support the current and future content of patient education programmes. Developing healthcare documentation that records the preferences and priorities for information of a CKD patient as they emerge and captures the patient’s temporal goals of information, information purpose and the influencing contextual factors, is essential to effectively communicate patient information needs within the multi-professional team. Finally the introduction of a patient-led information service is recommended that would facilitate and encourage self-management skills and effective information provision in clinical practice. Such a proactive approach implemented from diagnosis throughout the disease trajectory would meet the continuous information needs of CKD patients.

This thesis provides an analytical account of a qualitative research study into the experience of eight newly qualified children’s nurses during their transition into children’s community nursing teams in the North West of England. The study took place at a time when the recruitment of newly qualified children’s nurses into U.K. children’s community nursing teams was not only a new professional endeavour, but one that met with some resistance due to the prevailing attitude that the community was an inappropriate first post destination for them. The transition experience of their contemporaries, whose first post was within hospital based services, has been well researched. Indeed the resulting notion of “reality shock” led to major changes in clinical practice. However, little research attention has been paid to the experiences of transition of those who take up first posts in the community. The findings indicate that there were factors that both facilitated and hindered the development of their professional identity as children’s community nurses. Of significance is that the participants did not report the shock like reactions described by their contemporaries in acute hospital based settings. They described an ideal transition experience as one which included a period of lengthy and consistent support, the allocation of contrived workloads and continued support during independent visits. However, this ideal experience of transition was often disrupted through circumstances such as perceptions of being undervalued, lack of colleagues’ acknowledgement of the value of their undergraduate learning experiences and the allocation of complex cases requiring skills and knowledge beyond their competence level. The notion of an ideal experience of transition which accommodates individual differences during transition as described in this thesis offers a pragmatic solution to other children’s community nursing teams seeking to ease the transition experience of newly qualified children’s nurses. It also challenges the assumption that they are an inappropriate first post destination for newly qualified children’s nurses.

Chronic physical impairment of the hemiplegic upper limb (UL) is seen in an estimated 50-70% of stroke patients, who place a high priority on regaining upper limb function. Current therapy is insufficiently intensive, often not task-oriented and hence poorly aligned with the evidence base. Functional electrical stimulation (FES) has the potential to not only increase the intensity of task-focused therapy, but also provide certain unique features, notably direct excitation of lower motor neurons. However, current FES systems are limited in their functionality and/or difficult to use. Systems are also poorly aligned to therapists’ ways of working and uptake remains limited. To address these problems, a novel FES technology (UL FES Rehab Tool) has been developed. The control system design is reported in Sun, (2014). The aims of my thesis were to: 1) design a Graphical User Interface (GUI) that would enable therapists to quickly and easily set up an individually tailored library of FES tasks for each patient; 2) evaluate the usability and functionality of the UL FES Rehab Tool(software and hardware) in both laboratory (lab) and clinical settings. An iterative, mixed methods, five-phase usability engineering approach was used to design and evaluate the UL FES Rehab Tool. Phases one to three incorporated identification of therapists’ requirements, a user ‘assisted walkthrough’ of the software with expert and novice FES users and ‘rapid prototyping’ of the full system, using healthy participants. Further usability testing of the software & hardware was conducted in phase four with 1 physiotherapist and 6 patients, (total of 24 visits), in the chronic stage post-stroke. The work demonstrated in detail, for the first time, the impact of therapist involvement in the design of novel rehabilitation technology. To address therapists’ focus on setup time, using the phase four data set, a novel model to predict setup time was devised. This model was able to explain 51% of the variance in setup time based on two parameters, task complexity and patient impairment. Finally, in phase five, a summative usability evaluation of the final prototype was carried out in 2 sub-acute stroke units. Four therapists and 1 rehabilitation assistant used the UL FES Rehab Tool with 6 patients in the acute stage post-stroke. The UL FES Rehab Tool enabled all therapists and one therapy assistant to effectively deliver FES assisted upper limb task-oriented therapy to a range of stroke patients (Fugl-Meyer scores 8–65). The usability methods effectively captured objective and subjective feedback from therapists and patients. However the previous setup time model was unable to predict setup time, suggesting other factors were important in a clinical setting. Although participant numbers were low, the results suggested therapists’ predisposition to using technology and post-training confidence in using the technology may influence their willingness to engage with novel rehabilitation technologies. This study is the first to describe in detail the impact of a usability engineering approach on the design of a complex upper limb rehabilitation technology from early stage design to clinical evaluation. These methods can be generalised to other studies seeking to explore the usability of new forms of rehabilitation technologies.

Overall aim of thesis: To evaluate the effectiveness of a pre-designed school oral health programme (SOHP), aimed at the establishment of sustained twice-daily toothbrushing. Methodology: A unique aspect of this thesis was the use of a child-centred mixed-method design, targeting 6–7 year olds. Study one: Piloted a new portfolio of research tools (n=97, in 3 schools), to test the suitability of intervention materials for use in UK schools, and to provide initial contextual understanding of children’s knowledge around oral health. Study two: Evaluated a complex SOHP, using a one-month exploratory matched-cluster controlled trial (n=8 intervention and n=5 control clusters, n=256 children n=256), with a 6 month follow-up. Study three: Validated a children’s self-report questionnaire (n=108, 5 schools) against an objective measure (data loggers) in a one-month test-retest study. Results: Study one: there were a number of changes made to two of the three research tools (children’s focus groups and draw & write); and some initial changes were made to the SOHP materials. Study two: the current SOHP produced no overall intervention effect relating to children’s plaque outcomes and self-reported brushing rates. Post-intervention there was a significant association between sugar-snacking behaviour and group in favour of the intervention group, although this was not sustained at follow-up. Overall the intervention group’s knowledge improved, along with sub-cohorts reporting positive changes in toothbrushing behaviour. Study three: The children’s questionnaire showed good reliability across the 2-week test-retest period, but showed a statistically non-significant association between subjective and objective measures. Objective brushing behaviour highlighted the difference between weekday and weekend brushing rates, with children’s average brushing time being 71.93 seconds. Conclusion: 6–7 year olds are capable of being active participants and effectively expressing their current knowledge and behaviours regarding OH, hygiene and nutrition in research when provided with suitable research tools. Transferring a SOHP into the home is challenging but necessary to improve effectiveness. The use of data loggers can potentially aid evaluations by complementing self-report and providing objective feedback to children, parents and stakeholders.

Following the expansion of the European Union (EU) in 2004, migration from the new Accession 8 EU Member States to the United Kingdom (UK) has been identified as one of the most significant international migratory movements to the UK in recent times. The largest member of these states is Poland and the UK has been the most common destination for Polish migrants post 2004. Arguably, there is limited literature that focuses solely on women; indeed, women migrants were invisible until the 1970s. In relation to A8 migration, gender and gender roles are an under-researched area. The aim of this thesis is to fill this gap and offer new insights with regard to the influence of the migratory experience on Polish women’s lives and the way they negotiate their gender roles through migration. This thesis contributes new and unique evidence to the debates surrounding migration, gender, Polish women and comparative social policy, in particular with regard to the role of networks in migration; enduring and new push and pull factors; the icon of ‘Matka Polka’ and work-life balance. Through the use of 32 qualitative in-depth semi-structured interviews with Polish migrant women resident in two countries – the UK and Poland, this thesis considers the factors that motivate the initial and any subsequent ‘return’ international migratory movements undertaken by Polish women between the UK and Poland. Additionally, the ways in which Polish migrant women (re)negotiate their gender roles in regard to paid work and informal familial care across time and space are explored. It is concluded that motivations for migration as well as motives to remain in the host country are often related to economic factors and the availability of migrant networks. It is shown that the migratory process may indeed influence women’s perception of gender roles which seem to be re-evaluated post migration.

It is commonly stated proprioception or the perception of one’s own limb position, movement and effort is reduced following an anterior cruciate ligament (ACL) injury. Therefore, this thesis begins with an analysis of all current literature on this topic in the form of a meta-analysis. It became clear that the methods used to measure knee proprioception were very inconsistent and did not appear to provide normative levels of knee proprioception making it very difficult to syntheses results. This led to the thesis main objectives. The first study provided a reliable and valid method of knee joint position sense (JPS), the static component of proprioception, based on previous JPS protocols. This method was then used in the remaining studies to consider normative values of a UK population, the effect of ACL injury in both non-athletic and elite athletic populations, the effect of knee injuries (not including ligament damage) and the effect of fatigue on knee JPS. The most appropriate clinical method of measuring knee JPS using image capture as covered in this thesis was in a sitting position, from full extension in to 60-90 degrees of flexion and from 90 degrees of flexion in to 30-60 degrees of extension. Age, mass, height, BMI, activity level, knee condition (other than ligament injury) or fatigue did not appear to significantly affect knee JPS in an uninjured population. However, both non-athletic and elite athletic populations with previous ACL injury demonstrated significantly worse knee JPS when compared to controls. In conclusion, it would appear the only knee condition that reduces joint position sense ability is ACL injury. Although, it may also be possible the method is not sensitive enough to measure subtle changes in JPS in other populations due to large measurement error values. In the future it may not be necessary to place importance on knee joint position sense as it either may not be impacted by any injury other than ACL damage, or the methods used to collect JPS are not sufficient in measuring changes during rehabilitation. Additionally, it is important researchers consider the relationship between knee JPS and functional movements.

Title: Nursing Observation and Assessment of patients in the Acute Medical Unit Objectives: To generate knowledge and understanding of the observation and assessment of patients in the acute medical unit, where patient acuity and activity is unpredictable and length of stay for patients is brief. Background: Time and temporality pose challenges for the nursing observation and assessment of patients because unlike other hospital wards, the acute medical unit is a dedicated acute short-stay facility, admitting patients with highly complex medical illness on a 24-hour basis. Over the past fifteen years, political drivers for improved efficiency of hospital beds, combined with recent austerity measures, have resulted in shorter length of stay in hospital for patients. The implications of these for nursing practice and the observation of patients have not previously been investigated. Method: An ethnographic approach was applied to explore the nursing observation and assessment of patients admitted to an acute medical unit. Data were collected from seven nurse participants using participant observation and qualitative interviews over a six-month period. A thematic analysis was undertaken. Results: The brevity of nurse-patient relationships combined with a problematic ward layout resulted in adaptations to practice to ensure safe monitoring of patients, including frequent visual and verbal assessments of patients. Nurses observed for facial colour, expression, appearance and verbal response. Nurses employed explicit, tacit and intuitive knowledge to interpret observations of patients and safely managed highly complex care despite the challenge of limited time. Nurses demonstrated expertise despite having limited experience. Recommendations: Layout of the acute medical unit must consider ease of visibility for patient observation and impact upon nursing workload. Recognition of nurses' ability to safely observe patients is essential, rather than relying upon the use of paper-based observation tools. Acute medical nursing must be recognised as a distinct specialism, with appropriate standardisation.