Doctor of Philosophy (PhD) / The alarming rates of ill-health and social disadvantage amongst Australian Indigenous peoples has continued despite improved understanding of the determinants behind these conditions. There appears to be an urgent need to review and re-orientate health and social programs, from a deficit-focused to a strengths-based model, whereby a community’s capacity and resilience is enhanced utilising, and building on, existing strengths and resources. The current study set out to investigate the meaning and role of resilience in the wellbeing of Indigenous Australians. The aim of the study was to examine resilience within an Indigenous context, its potential role in strengthening the Indigenous response to adversity, and the prospective ways in which this may be used in initiatives aimed at boosting health and wellbeing in Indigenous communities. The study involved qualitative in-depth interviews and focus groups within the Indigenous Yaegl community of north-eastern New South Wales. This was achieved through extensive consultation with the community, and a strong commitment to upholding cultural sensitivities and ethical considerations. The data was analysed using a phenomenological framework, involving objective and in-depth thematic analysis, with specific focus on the relationships within the data and their associations with the research questions posed. The study indicates the resilience of the Yaegl community, involving individual, family and community level resilience, involves interdependent protective factors and support structures. The experience of hardship itself, and the ability to employ positive adaptational/coping skills and recruit a variety of protective resources are key to the development of resilience throughout the life continuum. The study demonstrates the importance of these mechanisms not only at the individual level, but also in the resilience of family units and the community. This appears particularly important within the Indigenous context where these levels of functioning are interdependently connected. The study has implications for health and social practitioners looking to broaden their understanding of the Indigenous experience, to one that acknowledges the many existing strengths and protective factors present in Indigenous communities. Practitioners and program developers would benefit from utilising this holistic model of resilience, in which individual, family and community based protective factors play important roles in the prevention of risk and the development of resilience. Programs incorporating this understanding are expected to be more effective in both service delivery and outcomes, because all levels of functioning would be viewed and addressed as interdependent elements in the development of resilience and response to adversity.

The thesis presents an examination of children’s nurse mentor experience of undertaking assessments at sign-off stage. There is a need to determine student nurse competence and competencies throughout preparatory training and pre-registration nursing students are supported by mentors or other suitably prepared supervisors (NMC, 2006; 2008a). Sign-off mentors (SOMs) were introduced by the Nursing and Midwifery Council (NMC) in order to strengthen mentorship. In the nursing profession, SOMs support and assess students who are undertaking their final practice learning experience to confirm the student nurse as either having achieved, or not, the practice requirements necessary in order to enter the professional register (NMC, 2008a, 2010a; 2010b). The area of nurse SOM experiences in the assessment of pre-registration students at the end of the nurse training programme has received little attention. Using an interpretivist, qualitative, case study research approach the experiences of twelve children’s nurse sign-off mentors in the North West of England have been explored and analysed. Data was collected from individual and focus group interviews and analysed using thematic analysis. The study identified six key themes which were: professional responsibility and development; expectations of students undertaking their final practice learning experience; previous mentor decisions; the need for sign-off mentor support following difficult decisions; experiences of passing and failing students and the physical impact of undertaking the sign-off mentor role. Findings from this study provide new insight and understanding of children’s nurse SOM experiences. There was no evidence children’s nurse sign-off mentors were failing to fail students. This study is important to those interested in the assessment of student competency including: mentors and sign-off mentors, employers, educators, patients, policy makers and researchers.

Introduction Research into the implementation of healthcare quality improvement collaborative (QIC) programmes has steadily grown in recent years. However, there has been little research into quality improvement (QI) after the collaborative has ended, and only recently has the issue of QI sustainability been discussed within the existing literature. The long term sustainability of QI remains a significant issue for all improvement efforts in healthcare. Variations in sustainability are likely to be attributed to differences in a range of contextual factors, for example, the environment, the organisational/patient safety culture, management styles and clinical practice. However, these influences do not expose the contextual factors that may be important at differing levels of an organisation. Aim The overall aim of the study is to identify the key contextual influences on the sustainability of healthcare QI success. The focus will be on the interaction between the meso (organisational) and micro (clinical front-line) levels, and how the processes and the context at all levels may affect sustainability. Methods A multiple, comparative case study, mixed methods approach was implemented, comprising of five comparative case studies from four clinical quality improvement teams and one management team providing renal replacement therapy within secondary and tertiary care in a regional healthcare provider. The study progressed in two sequential phases: Phase One of the study involved reviewing the statistical process charts of clinical indicators, to determine if success had been sustained two years hence. The Hospital xviii Survey of Patient Safety Culture questionnaire (AHRQ, 2007) was distributed to all clinical staff within the service to identify the patient safety culture across all clinical areas of the service. The questionnaire measured components such as teamwork, communication and adverse event reporting. Previously used in the pre-collaborative phase in 2010 (Nache, 2012), the questionnaire was repeated to all clinical staff (n=188) to enable comparative data three years after commencing the QIC. Phase Two consisted of 19 semi-structured interviews of staff at the micro and meso level of the organisation, including healthcare professionals directly involved in the QIC, line managers and members of the executive management team within the organisation. Results Phase One: The Statistical Process Control (SPC) charts indicated that 50% of the four cases studied sustained their initial QI success after a two year period. From a 50% return of the patient-safety culture questionnaire (n=95), analysis indicated a significant decrease in all components of communication, leadership, management and organisational culture across the service. Phase Two: Following thematic analysis, initial results indicate that the complexities of the healthcare environment can prevent QI spread, and lack of continuity in management at the meso level can influence QI sustainability. Organisational sub-cultures impacted on QI both positively and negatively, and the motivation of team members appeared to influence sustainability. Conclusion The study findings extracted three main contextual themes of management, communication and organisational culture that influenced the sustainability of QI. Macro driven targets and the influence on meso level sub cultures impact on QI at the clinical front line. Positive, consistent leadership at the clinical level can enable front-line staff to lead on QI initiatives and promote a culture of continuous learning and new emergent behaviours. However, changing meso level priorities can challenge the sustainability of micro level healthcare improvement.

This study examines the professionalisation strategies of British podiatry between 1960 and 1997, following the introduction of state registration as a pre-requisite for NHS employment. It is primarily concerned with relations within podiatry and between podiatry, medicine and the state. Analyses of these relationships are mainly informed by the Weberian concepts of social closure, professional dominance and autonomy. The major changes, opportunities and challenges to professional development in podiatry in the post-registration era are mapped in thematic and chronological sequence. Qualitative methods of data collection and analysis have been used to provide detail and depth in presenting a picture of the issues under investigation. Data was primarily collected from 27 key informant interviews supported with documentary evidence from both published material in the public domain and unpublished material in private possession. These consisted of documents derived mainly from primary and inadvertent sources. Reported efforts by the state registered sector to secure state support for the exclusion of unregistered competitors from practice or to prevent their use of common professional titles failed as a result of government opposition to professional monopolisation and its concern to meet the manpower demands of an expanding NHS podiatry provision. Despite advances in technology which have facilitated an expansion of role boundaries into the arena of invasive surgical practice and NHS reforms which have permitted its integration into the mainstream health service, traditional podiatric NHS practice now appears increasingly vulnerable to service rationalizations. Encroachment into other areas of medical and radiographic practice have led to inter-professional conflicts which currently remain unresolved, although medical dominance appears intact. This study suggests that any further podiatric role boundary expansion without medical approval or delegation is unlikely, as is amending legislation to establish a trade monopoly in the provision of footcare services.

During normal weight bearing the ankle, sub talar and mid tarsal joints function as a kinematic chain and their motions are interdependent. This chain has three important characteristics. Firstly, the motion in one of the components (joints) produces motion at the other components (joints). Secondly, the three joints are interdependent because the function of each is dependent on the position and motion at the other joints. Thirdly, the pattern of motion between the joints during weight bearing motion is fixed. The aim of this investigation was to determine the functional characteristics of the combined ankle, sub talar and mid tarsal joints (the rearfoot complex). A non invasive in vivo kinematic assessment was conducted to determine the relative rotations at the ankle/sub talar complex, the mid tarsal joint and the rearfoot complex, during weight bearing internal and external rotation of the leg in 25 subjects. The results confirm that the rearfoot joints operate as a kinematic chain. The motion at the ankle/sub talar complex suggests that the ankle is capable of a considerable range of transverse plane motion. The axes of rotation for the mid tarsal joint described in this thesis are the first for this joint quantified from a kinematic assessment and thus supersede the theoretical axes for this joint described in the literature. The predominant motion in the overall rearfoot complex is transverse plane motion. This would suggest that the primary function of the foot is to permit transverse plane rotations of the leg and proximal structures whilst maintaining the foot in a stable position of the floor. In contrast to some of the literature, the ability of the foot to accommodate the transverse plane motion of the leg is a function of all three rearfoot joints.

Health and well-being’ footwear positions itself in the footwear market between high street footwear and specialist therapeutic footwear. Manufacturers in this footwear category promote benefits when compared with standard footwear. However, the full exploration and validation of such proposed benefits requires scientific exploration through the application of footwear biomechanics concepts and techniques. The studies herein were undertaken to assess these biomechanical concepts in ‘health and well-being’ footwear, particularly in FitFlopTM footwear. The studies are experimental studies with repeated measures designs. A total of 128 individual participants volunteered, 28 of which were included in two publications. Variables were quantified using an in-shoe plantar pressure measurement system (with a bespoke insole), electromyography, 3D motion capture, force plates, accelerometers, a modified questionnaire and a custom-made mechanical drop-test device. The research identified that ‘health and well-being’ footwear can be manipulated to increase shock absorption, namely reducing the heel-strike transient magnitude (-19%) compared with a flip-flop. ‘Health and well-being’ footwear does induce instability at specific phases of the gait cycle, which is specific to the outsole shape of the footwear. For example the MBT shoe increased muscle activity relating to controlling sagittal plane motion. The biomechanics of gait are also altered compared to standard footwear styles, such as reducing the frontal plane motion of the foot in stance (-19%) and the magnitude (-86%) and duration (-98%) of gripping with the Hallux in swing compared with a flip-flop. The tested ‘health and well-being’ footwear was subjectively rated equally as comfortable as a control shoe with increased regional pressures in the midfoot (≈25%) and decreased peak pressures in the heel (-22%). Therefore ‘health and well-being’ footwear may influence the biomechanics of wearers however further exploration of meaningful differences and individual population differences is required. The studies emphasise the importance and relevance of testing walking, as well as running, footwear to the wider footwear biomechanics field and demonstrate how this may be integrated into research and development processes within a footwear company.

Sibling relationships are significant in the lives of people who have a learning disability. They usually form a major part of their social network and there is an expectation at government, social and family level that siblings will provide some degree of support in the event of parental decline. A mixed methodological approach was taken, utilizing a survey in Stage one and Interpretative Phenomenological Analysis (IPA) at Stage two. In the latter, 15 face to face semi-structured interviews were conducted to support the research aim of listening to the voices of adult siblings of people who have a learning disability, regarding their personal wishes or preferences in relation to a future support role. Three overarching themes were identified from nine superordinate themes: impact of learning disability, services, and sibling needs and recommendations. Key messages raised were that learning disability has a significant impact upon sibling lives throughout the life course; although the areas and degree of impact varies widely between individuals, most participants voiced concern about the future, particularly when older parents would no longer be able to provide care. Service issues were raised, as was the difference in role and function between families and service providers. In order to better meet sibling needs and recommendations for lifelong support, information and advice, more productive partnerships need to be established, particularly in the area of futures planning. This research presents the clear perspective that tangible benefits may be available as a direct result of association with learning disability. It also provides a deeper insight into parental response to learning disability alongside further rational for a lack of futures plans and why siblings may not want to co-reside with a learning disabled person. These findings have relevance to service providers, siblings of learning disabled people, students in the field of health and social care and wider society.

This thesis presents an account of trans people’s perspectives and experiences of domestic abuse, their social care needs and whether these are addressed by social care agencies. To enhance an analysis of social care intervention, the views of domestic abuse practitioners are included. By addressing the absence of trans people in discourses of domestic abuse, it aims to contest the prevailing heteronormative model of domestic abuse and broaden contemporary debates. Twenty four participants were recruited: fifteen trans people and nine practitioners. The theoretical framework incorporates feminism, social constructionism and queer sociology to accentuate the constructedness of identity, practice, meanings and interpretations as constructions located within discourse. Interview data was treated as narrative with multiple readings undertaken as part of a voice-centred approach to data analysis. In line with an abductive strategy, this work seeks to uncover the meanings and interpretations made by participants through their discursive practice in relation to gender identity, domestic abuse, social needs and social care intervention. It is argued that trans people’s experiences of domestic abuse is both similar to and different from those of cisgender (non-trans) people. Within intimate partnerships, trans domestic abuse maps onto the model of ‘coercive control’ offered by Stark (2013). Yet, it is proposed that trans people experience domestic abuse in familial contexts more and this type of abuse intersects with notions of honour and stigma (Goffman 1979 [1963]). Therefore, through a reworking of honour-based ideology, a new typology of domestic abuse is proposed: ‘transphobic honour-based abuse’. An evaluation of contemporary social care and domestic abuse work suggests that trans people are largely invisible as users of social care. Therefore, recommendations are proposed to improve policy and interventions in order to offer accessible and ethical interventions for trans people who experience domestic abuse. These recommendations aim to transform practice.

Many older women experience the loss of a spouse or partner in later life. Social networks and social support are widely thought to help buffer such traumatic events and ease subsequent transitions. This longitudinal study considers the significance of personal communities in managing the transition of later life widowhood. A series of qualitative interviews were conducted with twenty-six older widows over a period of eighteen months. Personal community diagrams were used to identify the structure of the women’s personal communities, allowing for the development of a typology. The content or expressive characteristics of these relationships were explored further through the women’s experiences of Christmas and the exchange of Christmas cards. Content and thematic analysis revealed four core types of personal community among the older widows in this study, comprising different combinations of family, friends and others. The continuity and discontinuity of these social relationships, as well as the re-arrangement of family and friendship practices, demonstrate the multifaceted and ever-shifting characteristics of personal communities during the transition of widowhood. The findings also illustrate the diverse, complex, and often paradoxical nature of personal relationships within structurally similar personal community types, which is often compounded by multiple transitions in addition to widowhood itself. Using the lens of personal communities over a period of time reveals that the management of transition incorporates not only social relations, but also personal agency, and flexibility. These combined factors appear to be more important to adaptation during later life widowhood than personal community type. The findings help to re-frame the existing dialogue on later life widowhood and social support.

Chronic back pain is an under researched area; the complexities of unseen pain in particular, present challenges to the sociological assumptions made about the concept of ‘sickness’. The lack of ‘visible’ signs and symptoms means that some people are left without a diagnosis. If left undiagnosed, their experience of chronic back pain becomes delegitimized and could result in the erosion of self-esteem, self-identity and personhood. Undiagnosed chronic back pain can undermine a person’s moral self through disrupting the person’s biography and self –esteem. Ultimately, people with chronic back pain need person centred approaches to care that support the restoration of the self. The aims of this study were to generate a theory of person-centred care predicated on the experiences of people who have chronic back pain. The research design was influenced by a constructivist paradigm, which underpinned a Grounded Theory methodological approach. A purposive sampling strategy identified 17 people with chronic back pain and 4 multi-professional teams who were involved in their care. Semi-structured interviews with people who have chronic back pain, and the multi-professional teams captured the experience of person-centred care and explicated meaning about its key concepts. Data were analysed using a constant comparative approach through which theoretical sensitivity developed and eleven categories emerged. The ‘conditional partnership’ became a core category, which formed a substantive theory to explain the experience of person-centred care. The key findings highlight the significance of legitimation on the chronic back pain experience and exposes the impact that ‘delegitimation’ has on the individual’s ability to mobilise resources and manage their pain effectively. This thesis presents the conditional partnership as a theory which explains the relationship needed to support person centred care. The theory suggests that person centred care for people with chronic back pain is underpinned by a conditional partnership which is made up of three conditions; being believed, believing in and non-maleficence which represent the expected conditions of health care and by health care.