• Narratives of personalisation in mental health: a collective case study

      Lovell, Andy; Coyle, David S. (University of Chester, 2016-11)
      This work describes the impact of personalisation on users and professional workers identities in four mental health care settings. The development and context of personalisation is identified and set within an emergent narrative of consumer choice and austerity. International personalisation research is compared and a discussion of UK mental health literature is presented. The social constructions of key participants are analysed through their narrative accounts as they undertook identity work while being involved with individual budget pilots, either as users, carers, brokers or mental health professionals. The work employs Stake’s collective case study as the method of combining semi-structured interview data taken from participants in four personalisation studies designed and led by this author between 2008-2011. Narrative social constructionist methods, positioning theory and story-line are used in the analysis to produce a framework of participants’ orientation to personalisation. The importance of nuance as opposed to binary construction towards personalisation is highlighted, as are the positioning actions of independent brokers for the success of personalisation. The importance of co-production and challenging professional asymmetry in health and social mental health care services is clearly made as are the implications for practice. The value of the proposed framework and possible future research are discussed.
    • The perceptions and experiences of e-learning within undergraduate healthcare education: A case study

      Brownsell, Michael D. (University of Chester, 2016-03)
      Introduction: The use of e-learning in healthcare education is being increasingly advocated and used, but can prove challenging. The need to explore educator’s experience and student perspectives in relation to this area of pedagogy was identified as a relevant area of study Study Aim: To explore and critically analyse the perspectives and experiences of healthcare educators and students regarding e-learning. Design: A mixed methods exploratory case study of one HEI’s use of e-learning. Methods: Quantitative descriptive data was collected through educator and student questionnaires from 34 academics and 127 students across four university departments delivering undergraduate healthcare related programmes. A sample of 12 module web spaces and associated documentation was reviewed. The data sets were considered in relation to the thematic analysis of 16 semi-structured educator interviews and 6 healthcare student focus groups. Results: Educator and student needs are interwoven during undergraduate healthcare provision. Differing educational philosophies, practices and culture across the cases created opportunities and challenges with e-learning. Two differing, yet potentially complimentary definitions of e-learning existed within and across the four departments which produced either congruence or conflict toward the varied e-learning approaches. Student respondents selectively engaged in what was primarily educator controlled e-learning. Conclusions: The findings highlighted the need for agreement and understanding of philosophical and pedagogical underpinnings which define and shape e-learning by educators and students, along with an awareness of differing professional cultures across which e-learning is required to operate. Originality / Value: The findings of this study offer a deeper understanding of the effect on educator and student engagement in e-learning of differing higher education and professional practice education cultures. A model is offered as a response to particular issues faced by the study respondents; whilst non-generalisable the model may serve as an enlightening guide for educators who are introducing or applying constructivist e-learning practices within undergraduate healthcare provision and benefit the student experience.
    • Perceptions of care and caring: An orthopaedic perspective

      Mason-Whitehead, Elizabeth; Mason, Tom; Flynn, Sandra D. (University of Liverpool (University of Chester)Countess of Chester NHS Trust, 2013-05)
      “Too often we underestimate the power of a touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring, all of which have the potential to turn life around,” (Leo F Buscaglia 1924-1998). Caring is a universal phenomenon (Leininger, 1988a, 1991) that influences the way we think, feel and act and is the focus of debate worldwide. Studied since the days of Florence Nightingale and reflected in the literature are numerous theoretical opinions in the search for a comprehensive understanding of caring in the health experience of human beings (Newman et al., 1991). This ethnographic thesis has a caring science perspective (caring in orthopaedics) with the aim of acquiring a greater understanding of perceptions of caring in an orthopaedic clinical setting from both patient and health care professional perspectives. There is a wealth of literature relating to caring which attempts to define and interpret its meaning from several theoretical perspectives. In respect of institutional or professional caring, nursing has historically been synonymous with the notion of care and caring, modest research has been attributed to caring amongst other health care professionals in the wider context. The study used a sequential exploratory mixed methods design and was underpinned by Watson’s Theory of Transpersonal Care in order to discover and illuminate the essential caring behaviours valued by both care givers and care recipients. A total of 30 patients and 53 health care professionals consisting of doctors, nurses, physiotherapists and occupational therapists participated in the study through a three stage approach consisting of questionnaires, observation and semi-structured interviews. The findings revealed both similarities and differences between patients and health care professionals relating to the importance of positive caring behaviours revealed during caring interactions. The questionnaires disclosed that patients statistically rated caring behaviours demonstrated by health care professionals lower than the professionals rated themselves. The data analysis from the participant observation and semi-structured interviews established that although all of the caring caratives according to Watson’s Theory of Care were evident in caring interactions they varied as to the number of times they were exhibited by the respected health care professional groups. Overall patient perception of caring focused upon behaviours related to the caring carative ‘assurance of human presence’ whilst health care professionals considered caring behaviours relating to the caring carative ‘respectful deference’ as the most important. This thesis highlights the need of the patient to feel ‘cared for’ and ‘cared about’ and in today’s modern health care system caring should not be monopolised by one profession but instead the caring concept embraced and the caring dais shared by other professions.
    • Personal grooming (beyond hygiene): a grounded theory study.

      Mason, Tom; Gidman, Janice; Mason-Whitehead, Elizabeth; Boulton, Michael J.; Woodhouse, Jan (University of Chester, 2015-10)
      Background: We are very individualistic in how we present ourselves to the world. Whilst we are healthy and self-caring we have control over the way we undertake self-groom. Once we need care the situation may change. In the setting of health and social care the emphasis has been on hygiene; aspects of personal grooming [PG] may be overlooked. Few studies exist in the health and social care literature that explore this crucial daily activity of living. Aim: This study aims to address the imbalance on what is known of PG. It seeks to thoroughly explore the concept of PG, identifying the normative activities involved, and the age-related behaviours that occur across the lifespan. Methods: Utilising a grounded theory [GT] methodology, an eclectic data collection approach was taken. Consequently a pilot group, four focus groups (child-focused; males 18-45; females 18-45; over-46), and a visual methodology formed the first phase of the study. The second phase consisted of a formal concept analysis, drawing on literature and data from the focus groups. The final phase of the study involved one-to-one semi-structured interviews with retired persons. A total of 26 participants took part in the study and both genders were represented. Analysis was undertaken using the range of coding consistent with a GT approach and the notion of constant comparison. Findings: New knowledge on PG emerged; an academic definition of PG; PG was found to have ‘four elements’: hygiene, appearance management behaviours, body modification and enhancement. There was a ‘spectrum’ of grooming recognised, which ranged from the wild, un-groomed state to that of being over-groomed. The term ‘allo-grooming’, which means grooming of another, was used to explore the part families play in social learning about PG. A timeline of PG behaviours was created to illustrate how PG changes over the lifespan. Additionally, information on grooming activities, other than those of hygiene, was recorded. Implications: PG is complex and the ‘one-size-fits-all’ approach of concentrating on hygiene may not meet the needs of service users. Some body areas, for example, are not included in the published documents that help to guide care services. There appears to a gap in educational programmes of health and social care workers, in respect to PG. Recommendations for practice, policy, education and further research are proposed.
    • A phenomenological investigation of pre-qualifying nursing, midwifery and social work students’ perceptions of learning from patients and clients in practice settings

      Newton, Jethro; Mason, Tom; Gidman, Janice (University of LiverpoolUniversity of Chester, 2009-08)
      Government policies have emphasised the importance of patient and client involvement in all aspects of health and social care delivery, with a corresponding impetus for their involvement in the education of practitioners. Professional education programmes adopt andragogical, student-centred approaches and incorporate both academic and practice based learning and assessments. Practice experience is recognised as a crucial aspect of student learning and has become a major focus of quality reviews in health and social care education. Whilst it might seem self-evident that students on practice placements will learn from their interactions with patients and clients, this is a relatively neglected area for formal modeling, evaluation and research. This study, therefore, explores pre-qualifying nursing, midwifery and social work students’ experiences of learning from patients and clients during practice placements. The research project is underpinned by a descriptive phenomenological approach and the extensive data are analysed using phenomenological reduction (Giorgi, 1989a; 1989b). Two key themes and six categories emerged from the data. The first theme is presented as the ‘Ways of Learning’ and this comprises the categories of: facilitation of learning; critical incidents/patient stories; and role modeling. The second theme is presented as the ‘Nature of Learning’ and comprises three categories: professional ideals; professional relationships; and understanding patients’ and clients’ perspectives. It is evident that contemporary theories, including andragogy, social learning, experiential, reflective and transformative learning theories, remain relevant to professional education. The new knowledge obtained in this research is that the most powerful learning opportunities result from unplanned, informal learning opportunities involving interactions with patients and clients. However, this is not fully explained by these contemporary learning theories. This thesis will, therefore, argue that complexity theory is relevant to the requirements of professional education programmes. It will present an overarching framework to explain the data from this study and will propose strategies to harness the complexity inherent in this important aspect of student learning.
    • Practice change and development: An insider view - a grounded theory study on the nature of nursing practice change

      Mason, Tom; Fallows, Stephen; Thomas, Mike; Meredith, Linda (University of Liverpool (University of Chester)University of Chester, 2012-04)
      Change is a common feature of nursing, influenced by prevailing governments as part of their political agendas. These changes have impacted both on the context within which nursing takes place as well as on the actual role of the nurse. For change agents who are implementing these changes, it is imperative that they are aware of how nurses respond to change in order that they can plan the most effective strategies. This thesis investigated how nurses understand their own practice changes, the process that they undergo, how resistance to change manifests and if nursing rituals have an impact on the process. Finally the thesis made recommendations based on the findings to facilitate effective practice change and development. The study was conducted in two parts. In-depth interviews with eight nurses from one acute NHS Trust made up the first part of the study. A further two interviews were conducted with eleven mental health nurses from an early intervention team in one NHS Mental Health Partnership Trust, and this constituted the second part of the study. Constructivist grounded theory was the research method employed in the design of the study. An underpinning theoretical framework of structural anthropology with specific reference to the work of Levi-Strauss was used to present the final grounded theory. The study found that nurses understood the process of practice change as a spiral with the most significant aspects of practice change at the bottom. These were the day-to-day changes that may or may not lead to permanent change. At the top of the hierarchy and of least significance were the changes imposed by their employing organisations or nationally. The overall personal process of practice change and development was identified from the study as a process that centres on the experiences that participants have in their workplace, a process of sense making, learning and intuition. A Practice Change Model in the form of a continuum was developed that described how nurses respond to practice change and development. The significance of this study is that the thesis was able to identify strategies for promoting effective practice change and development, aimed at nurses in practice, change agents at an organisational and national level, and the clinical link role within higher education.
    • Realities from practice: What it means to midwives and student midwives to care for women with BMIs ≥30kg/m2 during the childbirth continuum

      Steen, Mary; Thomas, Mike; Roberts, Taniya (University of Chester, 2016-12)
      Women with raised BMIs ≥30kg/m2 have now become the ‘norm’ in maternity practice due to the recent obesity epidemic. To date only very limited research evidence exists highlighting midwives’ experiences of caring for this group of women. This thesis aims to provide original research on what it means to midwives and student midwives on the point of qualification to care for this client group throughout the childbirth continuum.
    • Retrospective cohort study of type 2 diabetes mellitus (T2DM) in the Wirral peninsula: complexity science

      Nwaneri, Chukwuemeka (University of Chester, 2014)
      T2DM continues to be a public health burden with its increasing incidence, prevalence, and mortality risks. The aim of this thesis was to examine a population-based cohort of 22,000 people with T2DM diagnosed between 1 January 2000 and 31 December 2010 within the Wirral Peninsula, UK with the aim of: Assessing factors relating to all-cause, cardivascular-, malignancy-, and non-cardiovascular mortality; evaluating the role of glycaemic control, socioeconomic status, smoking, dyslipidaemia, blood pressure, obesity, and nephropathy, as predicting risk factors for mortality; assessing the influence of age at diagnosis, duration of diabetes, year of diagnosis and gender on mortality; examining the life expectancy and mortality patterns and measuring the years of life lost as a result of a diagnosis of T2DM; applying Complexity Science to the dynamic interplay of the various factors in T2DM that lead to unpredictability in health outcomes.
    • Social Work Discourses: An Exploratory Study

      Roscoe, Karen D. (University of Chester, 2014-04)
      This study aims to critically analyse and explore how social workers (operating in the adult social work practice domain) draw on wider social (and social work) discourses in accounting for the work that they do. Utilising purposeful samples of students and qualified social work practitioners, this exploratory study of discourses analyses the implications this has on the construction of the social work identity, role and practice (action). Driven by a series of research questions, the objectives of this research were: 1) To critically analyse and explore the discourses on which students and social work practitioners draw on in their accounts of social work practice; 2) To identify and critically analyse the subject positions and discursive practices (collective ways of speaking) of social workers in respect of these discourses; 3) To critically analyse how and in what way social workers at different stages of the career trajectory draw differently upon these discourses; 4) To critically analyse and evaluate the implications for practice and service users of the respondents’ subject positioning and the discursive practices that they employ; 5) Develop a critically reflexive method (model) for social work education and research in order to make recommendations for research, education and critical social work practice (in the context of self-awareness). As this study involves several people in the exploration of adult social work (Community Care policy context), it will contribute to knowledge of the meaning given to contemporary social work. It does so by expanding the concept of discourse analysis to the wider social context in which the overall narrative (story) is ‘told’. This research aims to understand how respondents draw on discourses in particular ways and includes an analysis of the contradictions and gaps within the overall narrative of social work. Stemming from wider pre-determined narratives that are available in social work cultures, this study not only analyses the words themselves by utilising discourse analytic tools, but demonstrates new ways in which to apply critical discourse analysis in the exploration of accounts of social work. In this examination, this research critically analyses and evaluates the implications these discourses can have on identity construction (personal and professional self), as well as on those social work intends to benefit (service users).
    • Stigma: Personality disorder and homicide in the U.K. red-top tabloid press, 2001-2012

      Lovell, Andy; McIntosh-Scott, Annette; Bowen, Matt (University of Chester, 2018-08-28)
      There is evidence of stigma towards people with personality disorder from within healthcare systems, but relatively little known about other aspects of stigmatisation. This study explored the image within the red-top tabloids of people with personality disorder who have committed homicide and how this may have contributed to the processes of stigmatisation. The analysis was underpinned by a symbolic interactionist perspective on individuals and society and was informed by the modified labelling model. The role the press plays in the processes of stigmatisation is elaborated through exploration of the theoretical models and empirical evidence. The data set for the thesis was articles published by the red-top tabloids between the years 2001 and 2012 (inclusively) that made reference to personality disorder. The data set was analysed using three methods: content analysis, corpus linguistics and frame analysis. The three methods were used in a mixed methods approach with a sequential design so that the results from one stage of the analysis fed into the next stage. The content analysis of the data set identified that of the 552 articles published about people with personality disorder, 42% met the criteria for being homicide themed. Analysis identified that there was a significant reduction in the proportion of homicide themed newspaper articles in the period 2007-2012 compared to 2001-2006 ((1, n=552) = 7.38, p < .05), however, the effect size was small (φ = .12). Corpus linguistics analysis was used on articles that were homicide themed and identified 22 words that were stigmatising in their use, and were used proportionally more frequently than a comparator data set. These words were categorised as either epithets (e.g. psycho, monster), qualities (e.g. evil) or contributing to the process of labelling (e.g. branded). Comparison between 2001-2006 and 2007-2012 identified a proportional increase in the use of stigmatising descriptors, but to a level that was not considered to be significant ((1, n=114110) = 1.53, p > .05). Frame analysis of the homicide data set identified a dominant news frame in the articles, referred to as lock them up and throw away the key. This news frame was structured on a model that the problem was a failure to protect us, the public, from the risk presented by them, dangerous people with personality disorder who commit homicide. The results of the study are discussed in relation to the model elaborated in the study of the role the red-top tabloids may play in the processes of stigmatisation. Implications for practice include using personality disorder in press guidance, and training for clinicians about attitudes towards people with personality disorder to include reviewing the impact of the press.
    • Understanding the diffusion of the idea of contact with nature to enhance health: An Eliasian case study

      Thurston, Miranda; Greening, Kim L. (University of Chester, 2015-12)
      In public health working in a less medical and more preventative way by focussing on the wider determinants of health, inter-sectoral collaboration, and evidence based practice have been advocated as ways to raise the health status of the population. In recent years, the idea of contact with nature to enhance health has come to the fore as one way to tackle current public health challenges: for example, diabetes, overweight and obesity, chronic liver disease, hypertension and mental health problems. Yet little is known about how this idea has diffused through the interdependent figurations of researchers, policy makers and into use through the actions of people in local organisations. The processes connecting these interdependent figurations are complex and, in the case of contact with nature, are not well understood. This is the research problem this thesis seeks to address, that is to say, the evidence into action process of an idea. The theoretical perspective of Norbert Elias is used throughout the thesis to analyse the diffusion process of the idea. Elias’s work is concerned with long term processes in human history; in adherence with his approach to sociological inquiry a historical context going back more than three generations provides the backdrop for the empirical work. An examination of the context illuminated the significance of the decade of the 1970s onwards to the present use of the idea of contact with nature in public health; notably the shift in discourse about hazards, risk and threats from nature to one of health enhancement. Norbert Elias’s own thinking and discourse about contact with nature to enhance health is used as a touchstone for the analysis. The empirical data in the thesis is generated through mixed methods, principally bibliometrics and content analysis, to reveal the diffusion and development of the idea over time and to show the way that the idea is framed when used by researchers, policy makers and by people within organisations. An Eliasian approach to case study methodology is utilised. Sub-study 1 revealed that empirical research literature about the idea emerged in the 1970s and that the number of publications per annum increased year on year until 2005. The empirical research was generated by researchers located across several continents and from different disciplines. Early researchers into the idea investigated the psychological benefits whilst latterly epidemiological studies have come to the fore. Sub-study 2 showed that the idea was taken up widely by policy makers in four government departments in England from 2000, with a peak in 2011. There were more references to the idea in the policy documents of the Department for Environment, Food and Rural Affairs than other government departments; the references of this department took an ecosystem services stance. Sub-study 3 showed that during July to October 2013 and within Greater Manchester, 36 organisations were providing and/or promoting activities which involved the idea of contact with nature on their websites. Of these 36 organisations, 16 (44%) were conservation/wildlife based agencies whose use of the idea included the pursuit of their own agendas and purposes. ix An analysis of the results, using the theoretical perspective of Norbert Elias, shows the involvement of many figurations of interdependent individuals, and the long term, largely unplanned, and non-linear character of the diffusion process. The empirical findings reflect the transdisciplinary nature of the research, inter-sectoral collaboration across government departments within policy, and the adoption of the idea outside of the traditional health service. People and thinking from the environment sector have greatly influenced the diffusion and development of the idea, and their involvement has widened the scope and form of public health action.
    • Understanding the Processes Involved in Implementing an Improving Access to Psychological Therapies Service: An Exploratory Study that Investigates Practitioner and Client Experience Regarding its Effect on Patient Pathways, Service Design and Overall Outcomes

      Pietroni, Patrick; Thomas, Mike; Steen, Scott (University of Chester, 2015-12-31)
      The English Improving Access to Psychological Therapies (IAPT) programme is a government-funded initiative that aims to provide timely and equitable access to evidence-based psychotherapeutic interventions, within a primary care setting. Despite the many achievements of the programme, there are several issues regarding research to clinical gaps, as well as a high rate of variation between sites concerning outcomes and attrition. This thesis explores the implementation process of the IAPT delivery model to understand which factors are influential in the successful uptake and integration of evidence-based psychotherapeutic interventions. The aims of this thesis are:  To explore, identify and analyse the implementation process involved in establishing and delivering an IAPT service.  To uncover the factors that either facilitate or impede its development to provide a more in-depth and detailed account of the implementation and operation of services.  To develop an understanding regarding the applicability of evidence-based practice and the IAPT delivery model in a clinical setting, for the provision of psychological therapies. I conducted a series of semi-structured interviews with practitioners delivering and implementing services, across seven sites, and clients, across three sites. The design and analysis followed an Interpretative Phenomenological Analysis, focusing on personal meaning and sense-making processes. The objective of the interview was to understand the implementation process regarding the IAPT delivery model, exploring how this influences personal experiences and client engagement. Additionally, participant narrative was set in context using open-access data collected and published by the programme. The analysis generated three master themes for practitioners delivering and implementing services including: ‘A Call to Action’ describing how participants regarded this process as a genuine opportunity to make a real impact in mental healthcare; ‘Contextual Influences on Service Operation’ which explores the activities in becoming a locally determined, adaptable and relevant service; and a ‘Focus on Relationships’ outlining the relational and collaborative work involved during implementation. For the client group, three master themes were generated including: ‘A Personal Journey: From Discovery to Advocacy’ illustrating the changing experiences involved during service access and engagement; ‘Perception of Self’ which portrays how individuals made sense of their engagement by judging what it meant to them; 5 and ‘Outside Factors’ which explores the role of others and the physical journey made in getting to services. The analysis suggested that both groups made sense of their experiences in complex and varied ways. Heavily influencing the implementation of the IAPT delivery model is the over-arching need to boost throughput and quantity, possibly at a cost of quality. Additionally, it is argued that the use of routine outcome monitoring in services is useful for reflecting on the implementation process and engaging clients. The key to successful implementation appears to be about achieving integration, requiring a whole-systems based approach that considers the mediating pathways into and out of services. In light of the findings and literature, the thesis proposes several recommendations for future practice and further research.
    • Using a feminist standpoint to explore women’s disclosure of domestic violence and their interaction with statutory agencies

      Mason, Tom; Keeling, June J. (University of ChesterUniversity of Chester, 2011-11)
      This thesis explores women’s disclosure of domestic violence, and is based on the findings of two research studies. The first study explored prevalence rates of domestic violence reported by women following childbirth. The subsequent narrative study explored women’s experiences of disclosure and their interactions with statutory agencies. The research was influenced by a feminist epistemology, recognizing the marginalisation of the women’s experiences from a subjugated relationship, addressing the power relationship between the researcher and participants and because of the significant disparity between gendered lives. The study was conducted in two parts. A survey of five hundred women in the immediate postnatal period within a large NHS Hospital participated in the first part of the study. The second study involved narrative interviews with fifteen women living within their own community who talked about their experiences of domestic violence and issues surrounding disclosure. Women’s stories about disclosure including the responses they received were influenced by cultural narratives. The theories of social power have been utilized as an explanatory framework and provide the theoretical basis of the analysis. The study found low levels of disclosure at two specific points along the pregnancy/childbirth continuum; during booking in clinic and in the immediate postnatal period. Furthermore, the findings revealed three specific tactics used by perpetrators to engage women in the early relational stage with the intentionality of exerting control and subjugation. These have been termed feeling special, feeling vulnerable and commitment. Whilst women talked of coercion and subjugation by their partners, they also talked of how their interactions with statutory agencies limited their agency. The significance of this study is that the thesis was able to challenge contemporary policies developed by statutory agencies in the provision of support to women who experience domestic violence. The thesis develops some understanding of the nature and role of cultural narratives and patterns of disclosure before suggesting new directions to further advance the findings presented. Finally, the thesis proposes recommendations to improve training for statutory agencies in providing a response to women disclosing domestic violence, suggesting a new direction in thinking about the facilitation of this training.
    • Visual perceptions of ageing: A multi method and longitudinal study exploring attitudes of undergraduate nurses towards older people

      Mason-Whitehead, Elizabeth; McIntosh-Scott, Annette; Ridgway, Victoria (University of Chester, 2015-12)
      Ageism and negative attitudes are reported to be institutionally embedded in healthcare. The unprecedented increase in the older population together with social perceptions of later life presents all those involved in the delivery of healthcare with considerable challenges. It was therefore timely to examine attitudes and perceptions of healthcare professionals towards older people. This study presents a critical visual exploration of the perceptions of ageing of undergraduate nursing students at a University in the North of England, based on the findings of a three year longitudinal study. The research employed a pragmatic standpoint where mixed methodology was adopted to explore perceptions and included the use of an attitude towards older people scale (KOP) (Kogan, 1961), visual methods (participants were asked to draw a person aged 75), a Thurstone scale and photo elicitation. The research design and construct was influenced by the epistemology of constructionism and discourse analysis. The research was conducted alongside an undergraduate nursing programme, and followed the natural journey of 310 students from one intake and involved three waves of data collection. The study established that the majority of participants had moderately positive attitudes towards older people the beginning of the programme and that these had improved for a significant number by the end of the study programme. From the quantitative data it was determined that age, gender, educational qualifications, practice learning, branch of nursing and contact with older people influenced the participants’ overall attitude score. The use of visual methods provided a narrative of the participants’ perceptions of later life and appearance dominated the imagery via the physical depiction of ageing and the ascetics of clothing and grooming. The influence of role models was seen to impact upon the production of the image via the depiction of grandparents and people they knew and the drawings identified some older people being active. The visual findings established that the undergraduate nurses in the study viewed older people from a socially constructed phenomenon and used symbols (hairstyle, clothing, mobility aids) to depict old age. The nursing programme was found to positively alter perceptions. The research findings have led to recommendations based on three prominent themes; 1) implications for nurse education and practice, 2) gerontology education and research and 3) future use of the research methods.