The thesis explores the focus of district nursing practice in order to identify areas of study for inclusion in the district nurse curriculum. The "focus" is defined as the point of greatest activity (Chambers, 1991) and so evolves from nursing actions. It is assumed that some nursing actions are dependent upon the patients'needs/problems identified in the assessment process. As all district nurse students are Registered General Nurses they are familiar with nursing needs in hospital and the knowledge that underpins them. The problems experienced frequently by patients at home were explored and compared with those that occur frequently in hospital. The differences in the problems between the two settings enabled knowledge specific to district nursing to be identified. Data was collected from hospitals and the community in one outer London Health Authority. The research was structured through Facet theory which allowed the focus and parameters of the study to be made explicit. The data was analysed using a multiple sorting task, multidimensional scaling procedures and statistical tests. The results demonstrated that a relationship exists between some problems and illustrated those that are likely to occur together. A difference was found between some common problems experienced by patients at home from those experienced in hospital. However, other problems occur with equal frequency and severity in both settings. This suggests that the focus of care is different at home from hospital but that a family resemblance exists. It was argued that the focus of district nursing is on health teaching, which is facilitated by the giving of physical care. Concepts fundamental to district nursing, which underpin the focus of care at home, were identified. Areas of study for inclusion in the district nurse curriculum were suggested and questions for further research raised.

Growing evidence suggests that dietary n-3 very long chain polyunsaturated fatty acids (eicosapentaenoic acid; EPA and docosahexaenoic acid; DHA) reduce the risk of coronary heart disease and stroke, alpha-linolenic acid (alpha-LNA) is the natural precursor of EPA and DHA and is an abundant and accessible source of dietary n-3 PUFA that can be further elongated and unsaturated in vivo. The overall aim of the project is to examine the conversion of alpha-LNA to its long chain metabolite, most importantly DHA. This aim was accomplished by a combination of a human dietary intervention study to assess accumulation of EPA and DHA from dietary alpha-LNA, and 13C-tracer studies of alpha-LNA & linoleic acid (LA) conversion to their long-chain metabolites. The dietary intervention trial was a 12-week parallel design in men expressing an atherogenic lipoprotein phenotype, a common source of lipid-mediated coronary heart disease risk. Diets were enriched with 18 g of alpha-LNA as flaxseed oil (n=21), with a high LA oil (n=17), or with fish-oil (6g/d n=19) as a positive control group. Thus the intention was to provide an increased intake of alpha-LNA with a low ratio of n-6 to n-3 PUFA (1:1 or less), minimizing competition between alpha-LNA and the abundant LA and, in theory, increasing the conversion of alpha-LNA to LC n-3 PUFA. The results from the dietary intervention indicate that, dietary alpha-LNA as flaxseed oil can increase n-3 membrane fatty acid contents, through a 3-fold increase in alpha-LNA (p <0.001)) and 2.5 fold increase in EPA (p<0.001) at week-12, decreasing in n-6:n-3 ratio (p =0.001), but not changing DHA level. In contrast the fish oil diet increased both EPA and DHA. Dietary alpha-LNA had 7% of the efficacy of preformed EPA from fish oil to increase membrane EPA levels. Subjects on the 13C tracer study were a sub-group of the intervention study, studied after 12-weeks on the high alpha-LNA (n=6) or high n-6 (n=5) diets. Subjects were given an oral mixture of 400 mg each of uniformly 13C labelled alpha-LNA and LA in a milk shake after an overnight fast. 13C enrichment was measured in fatty acids isolated from plasma at 1,2,3,7,10 and 14 days after the dose. Of the dose appearing in the plasma 35-45% was converted to EPA with no dietary effects. Some conversion to DHA did occur especially in the high n-6 group (3.9% of dose) compared with the flaxseed-oil group (mean value 0.8% of the dose; p < 0.05). In the single subject studied on the fish-oil diet there was a much lower conversion rate compared to the flaxseed-oil diet. The variability between subjects for percent conversion to DHA ranged from zero to 6.2% of the dose appearing in plasma. Taken together these results clearly establish the effectiveness of dietary alpha-LNA as a method of increasing the concentration of EPA, but not DHA, in membrane phospholipids, with up to 7% of the efficacy of preformed EPA. The increase in the EPA: AA ratio (eicosapentanoic: arachidonic acid) in membrane phospholipids with dietary alpha-LNA is likely to reduce the overall inflammatory environment with beneficial effects for long-term health.

A model is presented to describe the evaluation of hospital wards by nurses. The model is developed using the principles of facet theory and its family of multivariate statistics. An environmental evaluation is taken as an assessment of the utility of a setting. It is proposed that to make an evaluation, people must rely on their conceptualisations of using the setting. The model is a description of people's conceptions about interacting with an environment. It is tested by examining the structure of the evaluations that emerge from such interactions. Three facets are proposed to describe the interaction between the nurses and the ward setting. The Referent facet describes the functions to be served by the environment; that is whether the activity being facilitated involves interaction with other people, the layout of the setting or the environmental services. The second facet describes the activities. A distinction is made between the Type of Patient Care being provided, namely direct or indirect. The third facet describes the Level at which the Interaction between the individual and the referent takes place. The four levels identified are observation, access, direct contact and preventing disturbances. Together the facets form a three-way classification system to describe environmental interactions. To test the model, a ward evaluation questionnaire is developed with each item containing an element from each of the facets. The data from 1921 completed questionnaires are analysed using a smallest space analysis (SSA-1) and the cylindrex structure predicted by the model retrieved. The model is used to draw implications for ward design, to develop a concise instrument for future ward evaluations, and to develop a system to illustrate the relationship between the evaluations and the physical characteristics of the wards. The model is also used to provide empirical support for previous work, and evidence is presented to suggest that the ward evaluation model may provide the basis for a more general theory of environmental evaluation.

A constructivist approach is found by identifying its cross-disciplinary roots in prior research. The theoretical connections are an exposition of personal and moral issues in a science of human services. Self-discovery emerges as an alternative focus to institutionalised care for a first-year cohort in the planned closure of a psychiatric hospital. The development of three educational courses as the investigation progresses provide (i) an extract of the methodology, (ii) a demonstration of the heuristic nature of the research, and (iii) the utility of an industry and university collaboration in doctoral study. Because they are products of the research, the curricula provide no data as yet, but incorporate much of what was learnt during the course of the research. Three staff-supported residential settings provide the basis for an empirical study of a constructivist approach to self-discovery. The fieldwork is a video-taped record of triangulated data collection in the houses, the evidence for each of which is individually presented in narrative format. The data is a tapestry of multiple realities that decentres individual construing while demonstrating a will to know. The study provides guidelines (i) in the use of a constructivist approach to connect the centre with the periphery of a mental health service, (ii) for a unifying basis in multi-professional working, and (iii) for an empowering mechanism of personal support to replicate good practice in psychotherapeutic work.

The achievement of autonomous practice has been a clearly and consistently stated aim in nursing for many years. It is one which has driven significant changes in the education and preparation of student nurses, and one which continues to shape developments in clinical practice. This near universal, and perhaps uncritical, pursuit and endorsement of autonomy as a desirable attainment for nurses has its roots in commonly held beliefs about the status and influence enjoyed by more 'traditional' professions. Yet little is understood about the relationship between autonomy and nursing in the acute sector of the National Health Service (NHS). One of the key aims of this research is to explore whether nurses perceive themselves to be autonomous, and to identify conditions within nurses' work environment which either constrain or facilitate the development of autonomy. A second aim is to elucidate the relationship between the concepts of autonomy and influence. Having influence over managerial and resource decisions made within the hospital may be more important than having autonomy vis-a-vis nurses' ability to control their practice. Empirical measures of autonomy and influence were developed from data collected from 825 nurses working in 119 acute hospital wards in 7 RHAs, related to nurses' perceptions of the ward organisational environment. Three influence scales were developed associated with distinct managerial functions: influence over ward management, influence over the timing of ward and patient events, and influence over ward human and financial resources; and an autonomy scale. These scales were analysed in conjunction with scales measuring nurses' perceptions of other features of the ward organisational environment, and objective ward data about organisational practice, staffing characteristics and clinical specialty. Nurses' perceptions of autonomy were enhanced where care organisation was characterised by a high degree of individual nurse responsibility, and where the ward ethos of care was innovative. Social aspects of the ward environment and staffing resources were also important: nurses' perceived themselves to be more autonomous when they had a cohesive working relationship with ward nursing colleagues, and when there was a high degree of collaboration with medical staff. In addition, a high nurse/bed ratio and ward staff stability enhanced perceived autonomy. Perceptions of influence were particularly associated with a high ward grade mix, and individual nurses' clinical grades however. In general, nurses perceived themselves to be autonomous in their clinical practice, but to lack influence over managerial and resource decisions affecting the care they provide. This suggests that nurses have a narrow conceptualisation of autonomy, i.e. clinical autonomy, which is derived from the work organisation process at the micro, ward level. This type of autonomy is limited in scope and value however, because it makes little difference to nurses' ability to influence higher level hospital management decisions. The researcher argues that influence represents a missing, more enigmatic aspect of autonomy, and that consideration of both are vital to developing an understanding of nurses' position within acute NHS Trust hospitals, and to enhance nursing's professional development.

This phenomenological study firstly examines the concept of the 'therapeutic community' as it appears within contemporary British psychiatry. It argues that certain confusions and contradictions which are exhibited within this area of practice arise as an inevitable consequence of the medicalistic and psychologistic epistemologies upon which these communities are predicated. Secondly, it proposes a number of informing sources whereby the practices of a therapeutic community might be more soundly guided. Amongst these are the ethical writings of Aristotle, and the discussions of 'dwelling' which are to be found within recent European philosophical writings. In particular, certain writings of Heidegger, Levinas and Bachelard are seen to be important. Informed by these sources, it is argued, we may find ourselves in a position to embody theorizing in a manner which more befits the subject matter of the therapeutic community. In the third part, an illustration is offered, of one therapeutic community household within which these questions of 'dwelling' were raised, and whose therapeutic gesture was understood in terms of the hospitality of dwelling, rather than the application of psychological method. Discussion is devoted to the founding of this household, the embeddedness of its conversations within the fabric of the ordinary, and the issues which were raised in the course of its finding its own way. In the final chapter of this thesis, attention is paid to the matter of the evaluation of such therapeutic households, and to their relevance to the current social policy of psychiatric 'care in the community'.

The research enquiry using a sample of 20 NHS organisations with similar revenue and population characteristic profiles sets out to identify the information needs of the NHS General Managers and in doing so highlight the information that they need to meet their organisations' key success factors. The research identifies through the enquiry process the General Managers' information needs and describes the categories of those needs, the pressures and influences of the General Managers' working environment on those needs and the links to the influences that have been reflected in their information needs. In particular the external influence of the Department of Health and the business environment has not only changed the General Managers' information needs but affected the balance of power between the stakeholders, which in turn has affected those information needs. These organisational and environmental changes, health policies, stakeholder demands, and changes in the balance of power between the stakeholders has resulted in a change in the way in which the General Managers work with information, which has in turn increased the need for more accurate, timely and complex information. The research analyses the General Managers' understanding of their roles in the General Manager/patient/doctor relationship and analyses the potential areas of conflict arising when the patients' interests clash with the market-led (business) interests of the healthcare organisations and the diverse needs of the Provider, Purchaser and Regional Executive General Managers. These problems together with the effects of organisational resistance, organisational culture clash and system requirements and its effect on the information needs of the General Managers were examined for associated links with the difficulties that the General Managers experience in defining their information requirements. The research provides an understanding of the links between a market-led healthcare environment, the General Managers' information needs, and their attitude towards information as well as an understanding as to whether the patient, a key stakeholder, has benefited in the healthcare empowerment stakes as a result of the re-delineation of the General Managers' information needs and the impact upon their decision making. The information needs identified as a result of the research have shown them to have become business orientated with financial targets as a key measure and clinical performance (outcomes) increasingly being seen as the other key factor as an indication of success for the organisation. The hypothesis (Null Hypothesis) of the research asserts that it is not possible to link a market-led healthcare environment, the General Managers' information needs, their attitudes and behaviour towards information, and patient empowerment in such a way as to develop a model of information needs that is common across the Purchaser, Provider and the NHS Executive organisations. However, the research has developed as a first step, a series of outline models of information needs that will lead to a more complex and common model of information needs across the General Managers' organisational groups that will allow, when assessed against key success factors, a judgmental view of the ability of both the General Managers and their organisations to deliver their aims and objectives.

This study explores the care provided for physically disabled people who are admitted to acute hospital wards for the treatment of short -term illness. Two groups of 75 disabled and 75 non - disabled patients were recruited for the study on a matched pair basis, and a survey of 205 nurses was undertaken. The study involved an assessment of how well disabled patients could manage eight activities of daily life at home and in hospital. The experiences of disabled and non -disabled patients in acute hospital wards were compared by assessing patient satisfaction with six different aspects of care. The views of nurses about caring for disabled patients in acute hospital wards, their experience and training in the care of disabled patients are also explored. The study demonstrates no difference in the levels of satis- faction with care experienced by disabled and non- disabled patients. Patient satisfaction with all aspects of care was found to be associated with satisfaction with the communication of information, a factor shown to be equally important for both disabled and non -disabled patients. It was hoped that the theory of social roles would provide a theoretical framework for understanding the position of the disabled patient on an acute hospital ward. However, in the event, role theory proved not to be entirely adequate for this purpose. An alternative model is developed which takes into account the attitudes and experiences of nurses as well as the experiences of disabled patients on acute hospital wards. This is used to suggest ways in which improvements could be made in the care of disabled patients.

This thesis reports the results of a pluralistic evaluation of rota bed systems providing respite care to carers of the dependent elderly. Using a multi-method triangulated design the study examines: the sources and determinants of carers' stresses and rewards; the subjective views of the main stakeholder groups as to the benefits and problems of the rota bed system; the rota bed experience as indicated by the environment and regime of care and the activity levels of rota bed users at two contrasting continuing care hospital wards. Using data from a national sample survey of members of the Association of Carers, convincing empirical support is provided for the transactional approach to the understanding of carer stress. In addition the results extend the conceptualisation of caring to include sources of satisfaction. The benefits and problems of the rota bed system are explicated and, on the basis of these suggestions are made as to how both respite care and related services to carers might be improved. Within the context of recent policy initiatives consideration is given to the nature of professional responses to carers and their dependants with particular reference to the role of the nursing profession.

No description available.