Mona Wilhelmsson Göstas, School of Health and Medical Sciences, Örebro University, SE-701 82 Örebro, Sweden, mona.vilhelmsson gostas@orebroll.se Attachment styles are relevant to psychotherapy since they highlight the way a person handles interpersonal and emotional stress. This thesis aimed to examine how psychotherapy patients in the public mental health care system report attachment styles related to interpersonal problems and diagnosis before and after psychotherapy and to examine problems and changes and psychotherapy contract and process from patients’ experiences of cognitive behavioural oriented therapy (CBT) and psychodynamic oriented psychotherapy (PDT). The studies are based on data from patients admitted to psychotherapy within the public psychiatric services in Örebro County Council. Studies I and IV were quantitative and used self-reports to examine attachment styles and interpersonal problems before and after psychotherapy. Studies II and III were qualitative interview studies examining patients experiences of problems, changes and psychotherapy process. The patients were diagnosed with mood disorders, anxiety disorders, adjustment disorders and personality disorders and reported insecure avoidant and anxious attachment styles that correlated positively with interpersonal problems when they started therapy. Psychotherapy with CBT or PDT enabled them to turn attachment styles into more secure ones and decrease interpersonal problems Patients aged between 26 and 39, patients who attended 11-25 sessions and patients diagnosed with a personality disorder reported greater changes in secure related attachment than others. Patients described their problems as emotions that could not be regulated, as cognitive disabilities and as problematic behaviours that implied a self-centredness. During the course of psychotherapy, the patients gained abilities to handle their problems. The perceived self-centeredness changed which increased their participation in their life-context. Similarities across the therapy orientations showed that the creation of a new context was essential to pay full attention to the patient’s problems, and that the working method and cooperation with the psychotherapist made up a whole. To make the therapy effective, it is important to build up confidence in cooperation and secure base functions like offering predictability and shaping interventions according to the needs of the patient and their ability to use them.

People who are mentally unwell and have committed a criminal offence are cared for by forensic mental health services. Their treatment is provided in secure hospitals so that any risks to the public are minimised. The complex nature of the mental health difficulties experienced by this clinical population means that they are typically treated in secure hospitals for several years, incurring high economic and personal costs. The need for meaningful approaches to treatment and management of these individuals is therefore paramount. The first paper systematically reviewed eighteen qualitative research papers that explored stakeholder perspectives on the personal recovery approach to care in forensic contexts. Principles of personal recovery were perceived to be meaningful and applicable in forensic contexts if adaptations were made to overcome inherent barriers such as restrictions due to risk management. Methodological quality of the reviewed studies was limited by shortcomings in the transparency of study procedures. The second paper explored the experiences of a significant subpopulation of forensic service users who were discharged to the community subject to conditions including ongoing monitoring, then recalled back to a secure hospital due to a relapse in their mental state or other indicators of increased risk. Using grounded theory, a theoretical model was developed of how these individuals make sense of being recalled. This was found to be a recursive process influenced by their perceptions of events before their recall, during the recall itself, and their subsequent experiences.

Paper one is a metasynthesis of studies exploring mothers' experiences of recovery from postnatal mental illness. Four databases were systematically searched using key words and index terms to identify the qualitative literature exploring mothers' experiences of recovery from postnatal mental illness. Fourteen studies met the inclusion criteria and were critically appraised and synthesised. These papers reported the views of 395 women's experiences of recovery from postnatal mental illness. Five core themes emerged from the synthesis to describe four key processes that facilitate recovery. This experience begins with recognising the problem through crisis and relational distress. Women then go through the process of seeking help which consists of subthemes of accepting help and help to access help. The next process in the in the journey is achieving recovery which includes subthemes of sharing with others like me, coping strategies and noticing recovery. The final process of maintaining recovery consists of incorporating coping strategies into daily life; acquiring a different model of motherhood and processing the experience. The role of the family was interwoven through each stage of recovery. Recommendations were made for professionals who come into contact with this group of women and their families. The review highlighted gaps in the existing evidence and made recommendations for future research. The findings and limitations were discussed with reference to the existing literature. Paper two explored the role of the baby in 12 mothers' experiences of recovery from psychosis after childbirth. A thematic analysis of the data identified three core themes that described the role of the baby in the mothers' recovery. Findings revealed that the baby was central to women's recovery and could be experienced as both helpful and unhelpful. The baby interacted with the mother; increasing self efficacy and reducing emotional distress. The baby could act as a barrier to recovery by increasing the women's emotional distress and hindering access to help and self care. The findings recommended that women receive specialist treatment in mother and baby units where they can access interventions that support parent-infant interactions. The findings of the study add to the existing evidence base on recovery from psychosis after childbirth and highlighted areas for future research. Paper three is a critique of the research carried out in Papers one and two. This paper discussed the rationale for the research design in both papers. Approaches to data sampling and data analysis are reviewed with reference to researcher reflexivity. The search strategy and critical appraisal of techniques of the metasynthesis are also critiqued. Paper three closes with personal reflections and conclusions drawn from both papers.

Due to the improved availability of highly active antiretroviral therapy (HAART) life expectancy amongst people living with HIV has drastically increased. Older people, aged 50 and over now make up the fastest growing group of individuals living with HIV in the UK. Despite this little is known about their experiences of ageing with HIV. In addition, further still is known about older Black African women living with HIV in the UK, despite the complexity of their social and political context. This was, therefore, the first study to explore the lived experiences of this underrepresented group of women. The thesis adopted a phenomenological approach to examining how the intersections of older black African women's identities shaped their experiences of living with HIV in the UK. In addition, it explored the ways in which they coped with the devastating impact HIV appeared to have on their lives. Using interviews with seven women and interpretative phenomenological analysis, the results revealed three master themes. These were 'Spoilt Identities', 'A present without light and a future without hope' and 'Escaping the labyrinth of distress and uncertainty'. A detailed account of these master themes is provided. The findings are discussed in relation to existing literature, implications for clinical practice, methodological limitations and suggestions for future research.

Critical scholars have written about the ‘squeezed middle' and the new labour process of front line and middle managers generally, but there is a gap in the literature relating to both how changes to managerial work have affected those subjected to them and how individuals and organisations have attempted to respond to, and cope with, public sector cuts and challenges. Much of contemporary HRD writing on change management suggests that leadership development has a privileged role in adjusting the ‘worker' to the situation. However, given the implicitly unitarist nature of much HRD writing, this thesis argues that insights from such literature is inadequate or incomplete because it fails to consider the interests of managers as employees. The focus of this thesis is on middle managers' (MM) ability to overcome the public sector challenges associated with work intensification; control and skills adaption via learning and development initiatives. This qualitative research comprises a data set of 17 in-depth interviews and 34 complementary semi-structured questionnaire's with middle managers in the Hong Kong Civil Service. Thematic analysis revealed that whilst managers and the organisation benefit from leadership development in terms of human capital development, power differentials and structural impediments limit the capacity to benefit from social capital and networking opportunities provided. As such LDP cannot compensate for work intensification, leading to a stressed-out, disempowered, squeezed middle management cadre, which in turn impacts on public service delivery.

In this phenomenological study, I examined the educational experiences of six international doctoral students of Education at a Midwestern university. The purpose of this study is to understand how the participants make meaning of their educational experiences. Several theories influenced this study. These include critical theory, co-cultural theory, transformative learning theory and the concept of cultural scripts. A qualitative approach was used to gather detailed data from the participants. Data collection included a series of three in-depth, semi-structured interviews with each participant and two focus group interviews. All of the data collected were carefully coded, looking for three central topics of self reflection, transformative experiences, and meaning making. The participants' understanding of their transformation as learners tied closely to their academic accomplishments, which include completing tasks and assignments, being accepted in academic community, having articles published in academic journals, and presenting their academic work at conferences. Much of their transformation and meaning making related to their instrumental learning. The study suggests that educators should encourage students to broaden their frames of reference by inviting them to engage in meaningful discussion that is beyond instrumental learning in order for the students to develop critical thinking and to be in charge and accountable for their learning towards critical consciousness.

Bakgrund: En av fem vuxna i världen har hypertoni. Hypertoni behandlas i första hand med livsstilsförändringar och vid utesluten effekt läkemedelsbehandling. Behandlingen vid hypertoni förutsätter en god egenvård, trots detta upplever patienter svårigheter att utföra egenvården. Egenvården förbättras då sjuksköterskan ger information samt stöttar patienten att använda egna strategier för att kontrollera sin sjukdom. Syfte: Var att beskriva upplevelser av egenvård hos patienter med hypertoni. Metod: Litteraturöversikten bestod av tio kvalitativa artiklar. Analys utfördes enligt Fribergs femstegsmodell. Resultat: Presenterades i fyra huvudkategorier och tio underkategorier. I resultatet framkom vikten av kunskap och information för att patienter med hypertoni ska kunna bedriva egenvård. Patienterna upplevde svårigheter att följa läkemedelsrekommendationer relaterat till otillräcklig kunskap kring hypertoni. Brister i följsamhet orsakas enligt patienterna av otillräckligt stöd från vårdpersonal. Patienterna beskrev att brister i information samt följsamhet ledde till minskad tilltro till den egna förmågan, vilket försvårar egenvården. Slutsats: Patienter upplevde brister i egenvård vid hypertoni. En god kommunikation mellan patient och sjuksköterska leder till ökad delaktighet i egenvården. Mer behöver göras för att ge vårdpersonal den kunskap som behövs för att utbilda patienter kring egenvård vid hypertoni. / Background: One of five adults in the world have hypertension. Hypertension is mainly treated with lifestyle changes and when the effect is excluded drug treatment. Treatment for hypertension requires good self-care, however, patients experience difficulties in performing self-care. Self-care is improved when the nurse provides information and supports the patient to use her own strategies to control her illness. Aim: Was to describe experiences of self-care in patients with hypertension. Method: The literature review was based on ten qualitative articles. Analysis was performed on the basis of Friberg’s five-step model. Result: Was presented in four main categories and ten subcategories. In the result the importance of knowledge and information emerged to enable patients with hypertension to perform self-care. Patients experienced difficulties in following drug recommendations related to insufficient knowledge of hypertension. Failure in compliance is caused by patients with insufficient support from healthcare professionals. Patients described that lack of information and compliance led to reduced confidence in their own ability, which complicates self-care. Conclusion: Patients experience insufficient self-care in hypertension. A good communication between patient and nurse leads to increased involvement in self-care. More needs to be done to provide healthcare professionals with the knowledge needed to educate patients about self-care in hypertension.

This thesis explores the experiences of several pediatric health care providers in the Boston area. It identifies and examines the stories told by providers to discuss their profession, their decision-making processes, and the methods that they use to "know" themselves and their patients through the lens of current topics of interest in pediatrics, including the Human Papillomavirus (HPV) vaccines. Pediatricians, pediatric nurse practitioners, adolescent health providers, and pediatric focused gynecologists were recruited from several private, community-based, and academic medical center practices in the Boston area. This study used several qualitative data collection methods, focusing primarily on the use of semi-structured interviews while including participant and non-participant observations in two distinct clinical settings.

Initiating the use of Computerised information systems (CISs) has become a global trend, including in Taiwan. Although CISs sound promising for improving clinical effectiveness and efficiency, evidence demonstrating their actual benefits is still limited. How CISs influence nursing practice and professionalism is not widely known, and the actual implementation process is not well understood. Hence, this study explores (1) the impact of CISs on the role of nurses and their practice, (2) the context of developing and implementing CISs, and (3) the practice politics underlying the use of information technologies in a Taiwanese hospital. A single, embedded, qualitative case study was conducted. Data collection used multiple methods, combining elite interviews with nurse managers (n=13) and informatics staff (n=3), five focus groups with front-line registered nurses (n=25) and 47 hours of non-participant observation in six wards in the case-study hospital. Data analysis followed a thematic approach, comparing and contrasting patterns among multiple perspectives. Four major themes emerged from the analysis. Firstly, the development of CISs was a result of negotiated order and relied upon interdisciplinary collaboration. Through interdisciplinary interactions of negotiations, covert negotiations and renegotiations, the exercise of power and power imbalances were recognised. Secondly, a top-down approach was adopted in the implementation process. In order to move computerisation forward, head nurses acted as change agents in gaining compliance from nurses. Front-line nurses showed generally positive attitudes towards computerisation. Being daily system users, front-line nurses were relatively powerless and were compliant with the top-down implementation; however, they grumbled at the same time. Thirdly, through system design strategies to structure clinical activities and increase information transparency, CISs became helpful tools in achieving standardised practice, tightening up managerial surveillance and control and clearly defining employees' accountabilities. Finally, whilst convenience and efficiency were perceived as the results of computerisation, hardware problems and the burdens of the computerisation process created hidden work in nursing practice, which required nurses to care for computers whilst caring for patients. Through the lens of several social theories, the study findings indicated that power in developing and implementing CISs was not in the hands of the nursing profession. The findings manifested the disciplinary power of computer technology and also suggest that computerisation may de-skill the nursing profession which may reignite the technology and skilling debate. Although generally believed to facilitate performance efficiency, this study found that computer technology created unfavourable consequences, for example hidden work, which seems to be unrecognised in the literature. Computers became the nurses 'co-client' and consequently took time away from patient care so computerisation may not be as efficient and effective as expected. Finally, a qualitative case study was found to be an appropriate methodology to explore this complex issue comprehensively and holistically. However, this small, single case study was conducted in one location in Taiwan. More research is needed to verify the findings which may have significant implications for management, policy and practice.

Thesis title: Health Professional-patient communication in relation to weight managementBackground: Global obesity levels have doubled since 1980 and are expected to rise. It is associated with key health risks such as heart disease, some cancers and osteoarthritis and hence has considerable economic consequences for health care resources. Key policy guidelines recommend that all health professionals (HPs) should discuss weight management with their patients making every contact count. However, we know HPs find discussions about weight challenging due to lack of time, training and skills. Knee Osteoarthritis (KO) and obesity are inextricably linked and together with a rise in obesity levels and growing numbers of older citizens rates of KO are set to escalate. As obesity is the key modifiable risk factor for KO, discussions about weight are paramount. This thesis explored this relationship further from the perspectives of patient and HPs, focusing on KO as an exemplar condition where there is scope for improved weight management. Methods: Utilising qualitative methods, three studies were undertaken. Firstly, a systematic review and thematic synthesis was conducted of published literature of physicians' views and experiences of discussing weight management within routine clinical consultations, not specific to KO. Secondly, HPs' experiences of discussing weight in consultations with KO patients through semi-structured interviews were conducted with 26 HPs. Interviews were audio recorded and analysed using TA. A final study recruited 25 overweight/obese patients with KO and investigated their experiences of talking about weight with HPs. Results: Overarching themes were identified across the studies. Firstly, HPs are pessimistic about patients' desire to lose weight and their capacity to help them. Several factors lead physicians and HPs to be reticent to accept responsibility for discussions about weight. Within routine consultations and between HPs and KO patients, weight was viewed as a sensitive topic. Both HPs and patients recognized the difficult cycle of pain, reduced mobility and weight gain. Patients with KO desire patient-centred (PC) care but, despite HPs recognizing its value, they do not receive it. Both physicians and HPs lack communication skills in weight management. Conclusions: The work undertaken in this thesis demonstrates that barriers preventing effective clinical interactions about weight identified in routine consultations still exist, even when two conditions such as KO and obesity are inextricably linked. Although HPs and patients hold similar understanding of these interrelationships and recognise the value of PC discussions, HPs struggle in effective behavior change talk. HPs expressed impatience with the efforts of their patients. To readdress this imbalance all consultations about weight should be PC. Both physicians and HPs were inadequately trained to discuss weight and patients' views supported this. HPs working with overweight patients should be trained in evidence-based behaviour change techniques and PC communication techniques to increase their confidence to support patients in weight management. Finally, health psychologists have the skills to both deliver and guide discussions about weight.