• Incontinence after childbirth and the effect on female sexuality and quality of life

      Ellis, Roger; Hogard, Elaine; Doyle, Mark; Bryceland, Linda (University of Liverpool (University of Chester)Wirral University Teaching Hospital NHS Foundation Trust, 2007-08)
      Objectives To determine obstetric, maternal and fetal variables that increase the risk of postnatal urinary and anal incontinence. To establish how anal and urinary incontinence impact on Quality of Life (QoL) with particular reference to sexual psychology. Finally, to ascertain the extent of disclosure of incontinence problems to partners and health professionals. Design A longitudinal, prospective, repeated measures, cohort study using five data sources. Data was collected in the last trimester of pregnancy, at 6 weeks postnatal, 6 months postnatal and finally at one year postnatal. Setting Wirral University Teaching Hospital NHS Foundation Trust. Participants Primiparous women with no pre-existing disease (N=516). Participants were recruited after a normal 20 week obstetric ultrasound scan. Results Stress incontinence was reported by 39.7% antenatally, 28.2% at 6 weeks postnatal, 31% at 6 months and 26.5% at one year postnatal. Urge incontinence was reported by 23.5% antenatally, 21.2% at 6 weeks, 21.4% at 6 months and 16.4% at one year postnatal. Anal incontinence at one year postnatal was reported by 9.39%. Those participants under the age of 20yrs had higher rates of postnatal urge incontinence (p<.001) possibly associated with increased rates of infection in this group. BMI>30 was associated with higher rates of antenatal stress incontinence but was not significant in the postnatal period. BMI<20 was associated with an increase in postnatal urge incontinence. Prolonged periods of time in labour without bladder emptying was associated with increased rates of both urinary incontinence (OR 2.36) and anal incontinence (p=.026). Forceps delivery was associated with postnatal stress incontinence (OR 2.41). Although caesarean section appeared protective against urinary incontinence initially, long-term data show a progressive increase in reported rates of urinary incontinence even after elective caesarean section. Elective caesarean section was protective for anal incontinence. Faecal incontinence was significantly higher (OR 3.26) in the group who had their labour induced (12.1%) compared to those who had a spontaneous labour (4.6%). Perineal trauma was not associated with anal incontinence. However, it was associated with urinary incontinence throughout the postnatal year with anal sphincter disruption having the highest rates of stress incontinence (p<.005). Birth weight, duration of labour, feeding method, epidural anaesthesia and smoking were not significant. Overall, urinary incontinence appears to be a regressive condition, although the impact on QoL is cumulative and seems to increase over time. Some participants had a progressive, deteriorating condition which appears to be associated with a higher BMI or >6 hours from bladder emptying to delivery of the baby. Urinary and anal incontinence had a detrimental effect on all QoL domains. Those reporting nocturnal enuresis, pain, intercourse incontinence and urge incontinence were effected the most. The greatest impact is on the emotion domain. Only 8.7% with urinary incontinence and 9.7% with anal incontinence discussed their symptoms with a health professional. Discussion with a partner was 32.8% and 21.4% respectively. The most common reasons for non-disclosure were embarrassment, fear of not being taken seriously and not wanting to waste the time of the health professional. Those participants who did disclose tended to have multiple symptoms. Pregnancy and childbirth appear to have a detrimental impact on sexual psychology, irrespective of continence status. Those who reported incontinence appear to have less sexual depression than the continent group suggesting the adoption of defense mechanisms to preserve the sexual Self. Conclusion Generally, urinary incontinence is a regressive condition. Risk factors for a progressive condition have been identified. Younger pregnant women appear to be more prone to infection which can sensitise the bladder and result in long term urinary incontinence. Prolonged periods of time in labour without voiding increases the risk of urinary and anal incontinence and is associated with a deterioration of symptoms over time. Whilst for all other modes of delivery the rate of UI decreased over time, in the elective CS group, the rate of UI increased steadily throughout the postnatal year. These findings support previous studies and suggest a degree of under-recognition or under-reporting of anal sphincter trauma leading to dysfunction. The impact of incontinence on quality of life domains shows clear evidence that the condition has a detrimental impact on many aspects of an individuals well being. Those women reporting intercourse incontinence had the greatest impact on QoL domains. Few women seek help for their condition and a number of personal and organisational factors have been highlighted which contribute to keeping incontinence both secret and taboo. It is clear that what incontinent women think is affecting the way they feel and ultimately their behaviour. Psychological defence mechanisms are employed to justify their inaction.
    • Justice of truth? Alleged offenders with intellectual disabilities in the criminal justice system

      Lovell, Andy; Hellenbach, Michael (University of Liverpool (University of Chester), 2011-09)
      This PhD study examines how people who are intellectually impaired are processed within the criminal justice system. In this context it analyses the understanding of intellectual disabilities, criminal justice decision-making processes, and the constructon of crime and punishment by professionals involved in criminal justice. Despite significant changes in mental health legislation and greater awareness by professionals of issues around intellectually disabled offenders, previous research has demonstrated that this population remains disadvantaged when coming into contact with the criminal justice system. The study focuses on how the criminal justice system maintains its traditional way of operating when engaging with people who are impaired in their intellectual capacities and who, therefore, often have difficulties in processing information and understanding complex situations. The study draws on qualitative data generated through thirty five unstructured interviews with custody sergeants, forensic examiners, prosecutors, magistrates, judges and probation officers from three regions in the North West of England: Cheshire, Merseyside and Greater Manchester. Through those interviews, the provision of support to alleged offenders is examined and the process of legal representation evaluated. By analysing decision-making processes around vulnerable defendants, two conflicting views that influence cimrinal justice professionals in their strategic behaviour were identified: protecting offenders' rights and protecting the public from criminal behaviour. It is argued that the criminal justice system draws its normative and enforcement powers from a 'discourse of truth' that concentrates on capacity and intent. Defendants who are classified as vulnerable because of impaired intellectual functioning whereby capacity to reason and intellectual disability are functionally separated. This way, an alleged offender's vulnerability becomes a manageable object within the criminal justice system and is integrated into a person's risk management. The disjointed discourse around intellectual disabilities increases the risk that people with an impaired level of intellectual functioning become drawn into the mainstream criminal justice system and, therefore, further compromises the empowerment and social inclusion of this population.
    • 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.
    • 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.