This collection contains the Doctoral and Masters by Research theses produced within the department.

Recent Submissions

  • Managers' Perspectives of an Effective Health and Social Care Worker in the Independent Sector: An Ethnographic Study

    Templeman, Jenni; Barton, Janet; Kendall-Corry, Raymond J. (University of Chester, 2023-08)
    Aim: This thesis presents an ethnographic investigation into the perceptions of managers in the independent health and social care sector regarding the characteristics of effective health and social care workers. The study investigates the managerial perspective of the values, skills, knowledge, and functional behaviours regarded essential for providing high-quality care services to adults who may be at risk. Using an ethnographic methodology, the study seeks to glean rich and nuanced insights from managers who play a central role in moulding and supervising the Health and Social Care workforce. Background: Health and social care workers require a variety of skills and knowledge for them to be perceived as effective by their managers. The skill and behavioural requirements range from the practicalities of supporting people with their daily living tasks, including clinical support, to high levels of emotional intelligence to support the sociological, psychological, and emotional wellbeing of people who access health and social care services. Health and social care frontline workers require a sophisticated level of emotional intelligence with positive, personal attributes such as patience, kindness, empathy, and compassion. Methodological approach: An interpretive, ethnographic design was adopted for the study incorporating symbolic interactionism with social constructionism as a lens with which to analyse the outcomes from the research question. Individual, semistructured ethnographic interviews were conducted with ten managers (n=10), and 18 two focus groups were held in which participants were asked to identify the characteristics that, in their opinion, constitute an effective frontline worker. The leadership focus groups included eleven managers in total (n=5 + n=6) therefore twenty-one participants in total (n=21) plus field notes thus achieving triangulation. The data was analysed using Ricoeur’s thematic analysis framework. Findings: Communities of practice are naturally inherent in well performing teams. On a service level this is brought about through the behaviours of effective frontline workers, creating cultures of effective communication and continual, shared learning to enhance the lives of their service users. One may suggest a culture of experiential learning begins through the metamorphic, liminal experience of integrating staff members into the organisational culture. Liminality is present in the experience of individual workers, teams and the ‘living organisation’. It is a catalyst, in which processes happen spontaneously, leading to consideration of 21st century healthcare and compassion in caring; essential for the transformative, person-centred healthcare required in contemporary practice. Recommendations: Recommendations included the development of a professional identity through communities of practice, an educational push towards enhancing staff self-actualisation, and the cultivation of organisational culture, all of which would lead to compassionate care with a focus on facilitating service user safety and happiness.
  • Exploring engagement: A Constructivist grounded theory study of pregnant woman’s engagement with antenatal care health services in rural India

    Speed, Shaun; Roberts, Taniya; Chaudhary, Diksha (University of Chester, 2023-11)
    Background: Safe motherhood, a woman experiencing a healthy pregnancy experience, with a positive outcome and healthy living of women and newborns are an integral concern for global public health (WHO, 2016). The estimated global maternal mortality rate is 211 deaths per 100 000 live births and approximately 810 mothers died each day worldwide in 2017 from preventable maternal complications (WHO et al., 2019). Only 52% of women reported to have attended at least four ANC visits as per NFHS 4 (2015-16), along with 17% of Indian women who never contacted health facilities for visits (NFHS4a, 2017). Methodology: The research study has adopted Kathy Charmaz’s Constructivist Grounded Theory methodology. Methods: In-depth semi-structured interviews were conducted with eight initial purposive samples of pregnant women. The data was simultaneously analysed to gather preliminarily concepts which further guided the theoretical sampling of sixteen pregnant women and eight healthcare workers. All 32 interviews were audio-recorded with the permission and consent of the participant. The three stages of coding in Constructivist Grounded Theory methodology, Initial coding, Focused coding, and Theoretical coding were followed for data analysis. Findings: The core category consists of interrelated sub-categories; perceived Benefits and importance of Antenatal care health services; pregnant women and Health worker interaction and structural factors as a barrier to antenatal care. Pregnant women especially for a full and partial ANC, perceived ANC as an opportunity to gain assurance about their well-being. Family presence is crucial in women's ANC decision-making. A positive relationship with healthcare providers significantly influences ANC engagement. ASHA community health workers act as a crucial bridge between the community and the health system is one of the important social processes which encourage women. Women preferred the Ultrasound over complete ANC services and recognized it as a core component to reassure both the baby and the woman. Family members especially elder female strongly influenced women’s decision-making. Health worker-pregnant women interaction is pivotal, fostering trust and encouraging ANC acceptance. Conclusion: The study reveals varying perceptions of ANC among full, partial, and non-attenders, shaped by diverse factors influencing their engagement. A prevalent theme is the predominant view of ANC as curative rather than preventive care, reflecting a significant social process. Pregnancy is often seen as a normal, healthy event, affecting decision-making. Lack of autonomy emerged as a significant predictor for ANC utilization, highlighting the need for women-cantered care.
  • A Hermeneutic Study of a Paraprofessional Mental Health Initiative involving Medical Teams and Male Professional Footballers

    Kingston, Paul; Ellis, Caroline J. (University of Chester, 2023-07)
    The spotlight has only recently focussed on mental health in professional football. High-profile suicides alarmed the football community and players continue to take their own lives. Consequently, mental health disorders in professional football have become a topic of increasing interest in research, due to the serious consequences for quality of life, and the likelihood of the player’s predisposition to inflict serious self-harm. Aims Given the increased interest in and importance of mental health issues, mental health education and guidance for football medical teams is essential. The research aim was to investigate the role of the medical team in managing the mental health issues faced by male professional football players and establish whether a paraprofessional Solution Focussed Brief Therapy (SFBT) initiative could enhance that role. A total of thirty-four participants, working in Premier League and Championship level professional football, took part in this two-phased study. Nineteen were contracted players, thirteen were members of medical teams and two were PFA representatives. A Heideggerian hermeneutic approach was adopted and data was collected through fifteen in-depth interviews and four focus groups. In Phase 1, the problem of mental health disorders and mental healthcare in professional football was explored. In Phase 2, a pilot study investigated the feasibility of a SFBT intervention, delivered through a smartphone APP. Results All of the nineteen players declared mental health issues. De-selection, not injury, was the main reported issue. The majority of players and medics agreed that disclosing mental health problems could lead to de-selection from the team, for some further punishment, due to the value placed on maintaining a ‘mental toughness’. Therefore, if a sports psychologist was present at the club, the player may not seek help as it was dependent on trust in the individual. None of the players made use of the PFA counselling hotline, at any time, for mental health support. The majority of players would speak to a member of the medical team if confidentiality was guaranteed. None of the medical team members had any mental health education, and yet engaged in unofficial paraprofessional mental healthcare. All medical team members thought paraprofessional mental health education would be of benefit. The SFBT APP intervention was unanimously well received as a paraprofessional mental healthcare aid. Conclusions The SFBT intervention indicated it was clearly possible to develop a paraprofessional mental healthcare supporting role for players. Mental health issues of professional footballers could be managed more effectively if the appropriate education and SFBT intervention, from inside the medical team, was in place. This could potentially save lives. Recommendations for future strategies and further research have been detailed.
  • An exploration of the social and cultural functions of drinking alcohol within the home for professional middle-aged women: implications for public health

    Kingston, Paul; Kennedy, Lynne; Haydock, Deborah; Cowan-Williams, Gillian A. (University of Chester, 2022-10)
    Evidence suggests that middle-aged women in the UK are drinking more alcohol today than in previous generations, particularly those in professional roles. Similarly, the place of drinking is changing, too, with recent data suggesting that women within this age group are drinking more at home. From a public health perspective, liver disease is now the second leading cause of death in working-age people, and 5%-11% of breast cancer diagnoses in women are attributed to alcohol consumption. Research which seeks to understand why women within this demographic are drinking more at home remains limited. Alcohol research has, to date, focused primarily on younger people. The qualitative study, situated within the interpretivist paradigm, sought to understand whether social and cultural changes have impacted middle-aged professional women’s consumption of alcohol in the home. Unstructured interviews were undertaken with ten middle-aged professional women. Interviews were recorded, transcribed, and analysed using thematic narrative analysis. Bourdieu’s theory of practice was used as a conceptual framework, and narratives further analysed through a Bourdieusian lens. Findings indicate that alcohol is used as a means of relaxation, reward, and coping with pressure and stress, particularly for those with caring roles across ascendant and descendant generations. Increased availability, accessibility, and reduced cost have resulted in alcohol being part of the weekly supermarket shop. A positive portrayal of alcohol through both television and social media was found to increase consumption. Scepticism was displayed towards the government’s low-risk drinking guidelines. Furthermore, a lack of concern was noted regarding the potential detrimental impacts of alcohol consumption on health. Viewed through a Bourdieusian lens, findings indicate that habitus became a structure that generated dispositions toward an expectation of drinking at home and a normalisation of that behaviour for the women. Accumulation of capital enabled the women to become “connoisseurs” within the social field of home drinking, differentiating their taste in what they viewed as socially acceptable alcohol consumption, notably wine. Within the field of home drinking, women who consumed alcohol felt at ease as they were conforming to the game's rules—conversely, those who tried to reduce their drinking experienced feelings of unease. This research provides new insights into middle-age professional women who drink alcohol at home. Findings suggest that social and cultural changes have contributed to increased drinking at home for this population cohort. Recommendations for further research opportunities are made, and implications for public health policy and practice discussed. Highlighted is the need for future partnership approaches to tackle this increasing public health concern.
  • An ethnographic investigation into multidisciplinary team collaboration - the role of psychological safety in a high-secure forensic in-patient hospital in Germany

    Lovell, Andrew; Mitchell, Andrew; Chapman, Hazel; Theunissen-Schuiten, Lettie (University of Chester, 2022-06)
    Background: Multidisciplinary team (MDT) collaboration in high-secure forensic in-patient hospitals is, although essential to the work, hardly studied. The culture of MDT collaboration differs due to their composition and the environment. Psychological safety (PS), that is the interpersonal feeling that the environment is safe enough to engage in MDT collaboration, without fear for personal consequences, could support staff to construct and better accumulate knowledge about patients between the different professions. Aim: To explore factors of influence on the culture of MDT collaboration and PS in the constantly changing MDT in day-to-day life. To understand how interactions with the environment and people in the environment become meaningful and are enhanced or create barriers which prevent staff from engaging in MDT collaboration. To study the role of PS and which factors, if any, influence it and how they interact with each other. Methodology/methods: A symbolic interactionist ethnographic methodology was used, with an emic approach to data collection and an eclectic approach to data analysis. Ten observations of weekly treatment meetings and 13 interviews (with a psychiatrist, a psychotherapist, a social worker, a teacher, five nurses, two ward mangers, two occupational therapists) were conducted and analysed through thematic analysis (TA). Reflexivity was used to constantly feedback on the role and presence of the researcher in the study. Findings: Four central themes were discovered: a shared approach to care; support and informal relationships; leadership and power and hierarchy; and PS, influenced by all and influencing all. The themes are visualised in a model of the social construction of MDT collaboration and PS. They are distinct and interrelated and discovered on four levels of social interaction in the hospital. The absence of a shared model of care, the supportive relationships, leadership, and the personal interpretation of the interactions between staff exerted the most influence on MDT collaboration and on PS. The absence of a multidisciplinary shared model of care kept the features of the total institution (TI) and the totality of the medical model in place. The traditional inequality and power issues between the professions responsible for the treatment and their knowledge, and the supporting staff created barriers to effective MDT collaboration and PS. The locally constructed meeting chaired by the nursing staff, the relationships, support, sub-teams, and inclusive leadership and behaviour enhanced both MDT collaboration and PS as a team emergent state (TES). These factors promote a culture of equality, belonging and perceived value. However, without a shared model of care, the relationships and perceived equality and support in sub-teams promoted dependencies on the knowledge and the support of others and revealed detrimental effects of high PS in sub-teams on MDT collaboration. Implications: MDT collaboration is complex and requires an unequivocal, carefully designed setting informed by a shared model of care with meaningful roles for all professions, inclusive leadership, and supportive informal relationships. Findings include the need to: diminish the deeply embedded unequal culture of collaboration informed by the TI and the medical model; diminish the dependencies on knowledge and support of others; promote an innovative culture of safe MDT collaboration with no fear for personal consequences for its members. Further recommendations for practice, education, and further research have been made.
  • Registered Nurses’ experiences of working within professional and contractual boundaries: A Grounded Theory study

    Templeman, Jenni; Barton, Janet; Devlin, Bernadette (University of Chester, 2022-06-01)
    Aligned to the Nursing and Midwifery Council’s (NMC) The Code (2018a) and other supporting regulatory documents, Registered Nurses (RNs) are accountable to the healthcare organisation through an employment contract and must work within the remit of professional standards and organisational policies. Falling below explicit professional and organisational standards has the potential for repercussions for the RN, the public and the organisation. This research explores RNs’ experiences of meeting the needs of the patient whilst fulfilling the requirements of The Code (NMC, 2018a) in conjunction with operational policies in a small District General Hospital within the British Isles. As far as can be ascertained, this study is the first to focus on the topic of interest. To explore this subject area and to have generated a substantive theory of Professional Liminality, a qualitative constructivist grounded theory approach situated in the interpretive research paradigm was espoused. Participants were purposefully and theoretically sampled to take part in this study. 12 face-to-face individual semi-structured interviews were conducted with experienced RNs. The interview guide evolved and lengthened over the data collection process in keeping with a grounded theory approach pertaining to emerging theoretical interests from the participants’ answers. The grounded theory principles of data collection techniques, constant comparative method of analysis to code data, construction of categories and the development of theoretical themes were adopted to produce a theory explaining the relationships between the emerging themes. Analysis of the findings uncovered three themes: Governance, Professional discrepancies, and Professional disquiet. These themes highlighted a dichotomy between professional and organisational expectations, significantly affecting RNs’ daily clinical practice, and are contextualised in the theoretical framework of professional liminality, representing the complexity of the findings. A new model, Rules versus Roles (RvR), is proposed as an approach to address and resolve the precarious professional liminal positions in which RNs find themselves. Whilst The Code (NMC, 2018a) and operational policy are both vital; they coexist paradoxically. This research indicates that they would benefit from complementing each other to affect an evolving and dynamic contemporary healthcare organisation.
  • Quality of life and social support in rare genetic skin conditions: A mixed methods study

    Mitchell, Andrew; Mason-Whitehead, Elizabeth; Butterworth, Sondra (University of Chester, 2021-02)
    Aim The aim of this study was to explore the relationship between quality of life (QOL) and social support in adults living with rare genetic skin conditions, specifically Epidermolysis Bullosa (EB) Ehlers-Danlos Syndrome (EDS) and related conditions. Background Measuring QOL has become an increasingly important method of evaluating the effectiveness of health and social care interventions. Living with the effects of a rare genetic condition has a profound impact on QOL for the individual and families. Design Methodological triangulation was adopted, in a sequential mixed methods exploratory design. Three stages were included: a literature review, online survey (n=31), and semi structured interviews (n=8). Outcomes The literature review concluded that professionals should adopt a biopsychosocial approach to the management of rare diseases. The online survey found a positive correlation between QOL and social support. The role of the family was a prominent theme. Most participants indicated that emotional support was provided by family carers, and tangible (practical) support was the highest rated support need. Conclusion This study demonstrated was that health and social care practitioners, policy makers and commissioners have to make room for QOL perspectives that come from the patient. These are wounded storytellers whose narratives are subjective but are spoken through illness. Their collective experiences can influence the direction of their diagnostic journey and must be front and center of any rare disease implementation plans in a post COVID era.
  • A grounded theory exploration into situational adaptation strategies developed by Paramedics when dealing with mass casualty incidents

    Finnegan, Alan; Templeman, Jenni; Hooper, Craig (University of Chester, 2020-11)
    The Manchester (U.K.) Arena bombing took place on the 22nd May 2017 at 22:31, when a suicide bomber detonated an improvised explosive device in the foyer of the Manchester Arena, as the crowd was leaving an event. The attack claimed the lives of 22 people, and a further 116 people required medical treatment, mostly for ballistic injuries. A key objective for Ambulance Service Commanders was to establish a casualty management system consisting of clinical triage, treatment, and transport of patients from a Casualty Collection Point into the hospital network. To achieve this, two Hazardous Area Response Teams were deployed alongside Consultant and Advanced Paramedics. The purpose of which was to provide point of injury care within the vicinity of the blast area. Whereas previous studies have identified how individuals react to the biopsychosocial response to traumatic incidents post the event, understanding how Ambulance Service personnel adapt to situations while deploying to, or during mass casualty incidents, remains an area that has received limited research in relation to defining empirical evidence. This study aimed to identify a process that either supported or inhibited Paramedics in achieving situational adaptability when dealing with a mass casualty situation. Constructivist Grounded Theory was used as the chosen methodology, with fifteen Paramedics volunteering to participate in the research. Analysis identified eleven theoretical categories, which were then divided into four theoretical themes. Combined, these formed the basis for four major theoretical propositions: ‘Training & Education’, appropriate application of ‘Incident Management Frameworks’, established ‘Peer Support Networks’, and individual reaction to ‘Stress stimuli’. This study makes a novel contribution to the phenomenon of situational adaptively. The significance of the resulting theory is that situational adaptability can be enabled through the application of effective decision making strategies, being able to draw on previous experiences, along with effective scene management. This along with communication strategies, support from peers, the incident commander, and multi-agency partners. Key identified inhibitors are presented as situational stressors, perceptions of threat, risk appetite, and environmental stimuli. Consequently, it is now possible to provide four recommendations for Paramedics preparing to respond to mass casualty incidents.
  • A modified grounded theory study exploring the impact of military service in Northern Ireland on mental wellbeing

    Kingston, Paul; Taylor, Lou; Finnegan, Alan; Frith, Anthony (University of Chester, 2021-11)
    Military service in Operation Banner during the Northern Ireland Troubles posed significant challenges for individual soldiers. The purpose of this study is to explore the impact of service in Operation Banner on the mental wellbeing of veterans who served in this conflict, and factors that have hindered or facilitated acquiring help in those who have experienced mental distress. This is a qualitative study that has utilised a modified grounded theory methodology and adopted a symbolic interactionism theoretical framework. Data were collected in semi-structured interviews with 16 veterans, recruited via advertising in newsletters distributed by veterans’ organisations to their members, advertising via posters and local radio and through snowballing. Data analysis was by open and focussed coding, supported by computer assisted qualitative data analysis software. The study confirms that for the majority, military service did not result in long-term mental distress and participants gained useful career and life skills. Yet, for some mental distress has persisted. Since leaving Operation Banner, the ability of veterans to cope with the past and meet present or future challenges has been through a combination of innate skills, resilience, individual initiative, outside support, and making use of opportunity. For some, though, coping has been hindered by internal barriers such as self-isolation, emotional suppression, legacies of military culture and veterans’ perceptions of indifference or even hostility by society and politicians. These barriers have led to some veterans to being predominantly oriented towards the past and unable or unwilling to seek help, a situation made worse by threats of prosecuting veterans, which have reinforced memories of the past. This study theorises, therefore, that there is no single way to help these veterans without understanding each veteran’s perception of themselves. When this self-identity is predominantly past-oriented, internal barriers negate the relevance of external help. When the veteran’s self tends towards future-orientation, external barriers to accessing help are more relevant. Understanding this individuality of self-perception may help to address factors that are maintaining past-orientation. Yet, for those who seek a resilient future, providing the right services, at the right time and in the right format is critical. This study helps to fill the relative gap in qualitative studies on UK veterans and those from Operation Banner in particular. Recommendations are made for the support of Operation Banner veterans and for future research.
  • An analysis of the acceptability, feasibility, and utility of the Global Mental Health Assessment Tool for Primary Care (GMHAT/PC) in a UK primary healthcare setting: a practice-based mixed methods study

    Mason-Whitehead, Elizabeth; Sharma, Vimal; Quinn, Bennett N. E. (University of Chester, 2021-02)
    Introduction: Published evidence shows that at least one in four people at any one time have mental health symptoms, most commonly of anxiety and depression. This is set against a background where the evidence demonstrates that primary care in general is poorly equipped to identify, diagnose and manage mental health disorders. The effect of these disorders affects the individual’s physical and social wellbeing and has an impact at all levels of Society. This study investigates the acceptability and feasibility of the Global Mental Health Assessment Tool for primary care (GMHAT/PC), and the impact of using it on the confidence and self-rated competence of healthcare workers. The Global Mental Health Assessment Tool for primary care (GMHAT/PC) is a computerised semi-structured interview tool to support a healthcare worker in the assessment of patients presenting with mental health symptoms. While single diagnosis tools are now more widely used in UK general practice, semi-structured mental health interview tools are not. GMHAT/PC was developed in the UK using resources from both community mental health services and primary care. Used in clinical practice, GMHAT/PC guides a healthcare worker through a comprehensive mental health assessment and its greater use has the potential to increase their diagnostic accuracy. With diagnostic accuracy comes more appropriate patient management. Method: The study deploys mixed methods research strategies in a UK general medical practice setting. Fifty-five healthcare workers were trained in the use of GMHAT/PC. They provided pre- and post-training self-ratings and participated in semi-structured interviews to provide views of the feasibility of the tool and its impact on their confidence and self-rated competence in mental health assessments. After training, the healthcare workers interviewed 198 patients with mental health symptoms using GMHAT/PC. The patients completed a questionnaire exploring their views of the time taken for the interview, whether it addressed their symptoms and whether they found it acceptable. Seventeen patients were also interviewed to further explore their opinions. Results: Ninety-nine per cent (99%) of the patient participants found the use of GMHAT/PC in their clinical assessment either “somewhat acceptable” or “very acceptable” (2 (1) = 6.636, N = 198, p = .010). Most healthcare workers identified time as a barrier to GMHAT/PC’s feasibility but viewed its use as feasible, provided that additional time was available for the assessment, such as extra appointment time, arranging an appointment at the end of a consulting session, or delegating the assessment to another healthcare worker with less time pressures. There was a statistically significant improvement in the self-rated competence (T = 253, z = 4.221, p < .001) and confidence (T = 378, z = 4.560, p < .001) of healthcare workers still in undergraduate training. For healthcare workers working under the supervision of a fully qualified general practitioner, statistically significant improvements were also seen in self-rated competence (T = 73, z = 2.801, p = .005) and confidence (T = 150, z = 3.491, p < .001). There was no statistically significant change in the confidence and self-rated competence of fully certified practitioners. Conclusion: The results show that the use of GMHAT/PC is highly acceptable to patients. Its use is feasible provided additional time is made available for the interview. There were improvements in the confidence and self-rated competence of undergraduate healthcare workers and those working under supervision. This research is important because it shows how the use of a tool such as GMHAT/PC could support healthcare workers in their practice, facilitating more accurate diagnoses and hopefully reducing the burden of mental health disorders for the individual and their societal settings. Future research should assess the value of semi-structured interview tools, such as GMHAT/PC, in developing trainee healthcare workers’ skills in mental health assessments, most particularly for common mental health disorders which cause significant disability for a large proportion of Society. Healthcare workers were concerned about the additional consultation time required for the GMHAT/PC interview. Future research could assess the impact of a semi-structured mental health interview on the patient’s subsequent consulting patterns.
  • Flexible shared parental leave: Shaping infant-feeding decisions in the UK - A longitudinal explanatory sequential internet-mediated mixed methods study

    Mason-Whitehead, Elizabeth; Wyndham, Delyth (University of Chester, 2020-09)
    Infant feeding is an enduring public health issue. The changes made to parental leave entitlement which came into effect in April 2015 in the United Kingdom (UK) have the potential to impact infant-feeding decisions. The introduction of flexible shared parental leave (SPL) remodelled maternity and paternity (or adoption) entitlement, enabling parents to share up to 50 weeks’ leave. The discourse has not yet considered this policy shift fully, nor has research comprehensively examined whether it will influence parental feeding decisions. The research design was informed by a narrative literature review followed and a systematic review of the literature, which indicated that few studies consider both infant feeding and parental leave. The systematic review found that focus of the discourses tended towards breastfeeding and maternity leave. In light of the interdisciplinary nature of the topic, a longitudinal explanatory sequential mixed methods design was selected to comprehensively address all strands of the research questions. The research was framed by a theoretical framework meta-model derived from Belsky's (1984) process model of the determinants of parenting, set within Bronfenbrenner's (1977, 1979) ecology of human development (later termed the bioecological systems model (2005)) and informed by a pragmatist lens. A sample of parents of infants born in April 2015 (the first eligible for shared parental leave) were surveyed via online questionnaire. At three points over the course of 12 months, the parents were asked to detail how their infants were fed and about leave decisions. Following on from this, a subset of parents were interviewed to illuminate the decision-making process further. The study aimed to baseline behaviour at the point of policy implementation and record attitudes towards shared leave. The outcome of the research is an initial evidence base documenting infant feeding patterns in the UK in 2015, in the context of a potential future shift stemming from the introduction of shared parental leave. In line with expected projections (BIS, 2013), take-up of shared parental leave was low within the sample of parents who took part. Of interest, the small number that did opt for shared parental leave reflected the wider sample tendency towards breastfeeding at 24-hours, yet mixed feeding to 6 months. Nevertheless, the parents that took part did not shy away from revisiting feeding decisions made in light of day-to-day practicalities, any issues they faced and the development of their infant. The study provides insight into the approach of parents opting for mixed feeding i.e., selecting the feeding mode(s) and/or substance(s) or mode(s)/substance(s) seen as most appropriate at the time. It is atypical (contrasted with conventional definitions applied within the research discourse) in disaggregating breastfeeding and breast milk feeding. Finally, the research further evidences the complexity of the narrative in parental decision-making. In view of the findings, further research is needed to document shared parental leave take-up and how parents are choosing to apportion it. A reconsideration of infant feeding definitions by the relevant agencies, to further the granularity of research data in relation to breastfeeding, breast milk feeding and mixed feeding (mixed mode, mixed substance or mixed method - mode and substance - feeding) would be welcome to improve research outcomes. Moreover, as a result of the discontinuation of the quinquennial Infant Feeding Survey series, there is a need for systematic, low cost research at regular intervals to supplement the modest infant feeding data collected via the Personal Child Health Record programme. Without this research, the significance of the impact of the parental leave policy reform in the UK on infant-feeding decisions may be overlooked.
  • Employment support needs of personnel undergoing a medical discharge: a phenomenological and IPA study based on the experiences of British Army Veterans and Stakeholders

    Thomas, Mike; Mason-Whitehead, Elizabeth; Flood, Grahame H. (University of Chester, 2020-10-30)
    Wounded, injured and sick (WIS) military personnel from operations in Iraq and Afghanistan 2003-14 initially lacked comprehensive holistic recovery support. An Army Recovery Capability (ARC) evolved to improve such support. Future employment is an important factor in recovery and transition. This study examines the employment support needs of Army WIS likely to be medically discharged. Until this study, little research specifically considered such needs. The study examines military to civilian Transition in its widest sense. Holistic Transition involves coming to terms with ‘the new me’, including a civilian identity in a timeframe preceding and extending beyond military discharge. The voice of individual WIS personnel has been lacking in reviewing recovery and transition. Using Interpretive Phenomenological Analysis (IPA), data from twelve medically discharged veterans was triangulated against data from five specialist employment consultants and six military and charity stakeholders. The main findings are that the employment needs of the WIS are not fully defined, identified, assessed or reviewed by the chain of command. Methods of effectiveness (MOEs) are lacking in the MOD, hampering the Army’s capability to manage change and assess the effectiveness of its processes and programmes. A lack of resources, unsynchronised policy, poor communications, and a gap between intent and delivery causes variation in support from the chain of command; whilst compensating charity resources mask inefficiencies in the MOD. Recommendations include a major review of the ARC and the medical discharge process; treating employment support as a subset of a broader Transition; the development of MOEs; greater compliance with policy and improved assurance; further research to examine individual WIS needs and outcomes and the use of identity process theory to enhance understanding of the challenges of change facing service leavers crossing the military-civilian divide. A life-course view is recommended to improve military reintegration and the optimisation of available resources.
  • Social Care Workers’ Experiences of Assessing Parents with Learning Disabilities: An Interpretative Phenomenological Analysis Study Based in the Northwest of England.

    Lovell, Andrew; Constance, Lyndsey J. (University of Chester, 2020-06-26)
    Aims: Qualitative research has identified a number of issues when working with parents with learning disabilities. Pre-conceived ideas, professional discrimination and a high percentage of children living away from the family home have featured heavily in the literature. However, less is known about the assessment process, and how practitioners adapt their skills to assess this parental group. The current study therefore aimed to gain an in-depth understanding of the assessment process, utilising a qualitative approach. The study focused upon the experiences of social care assessors from children’s and adult services, and sought to explore the following: the approach social care workers adopt when assessing parents with learning disabilities; if appropriate knowledge is embedded into practice to assess competently; experiences of the application of the PAMS 4.0; multi-disciplinary approach to assessment, and how this exhibits in practice. Method: Semi-structured interviews were carried out with fourteen frontline social care practitioners from children’s and adult services who had direct experience of assessing parents with learning disabilities. The transcripts of the interviews were analysed using Interpretative Phenomenological Analysis (IPA). Results: The analysis produced four master themes. These were; inadequate knowledge to understand complexities; hierarchy; reasonable adjustments; assessing parental ability. An analysis of these master themes and the related super-ordinate themes is presented. Discussion: The results are considered in light of the experiences of the participants, and how this impacts on the assessment of parents with learning disabilities. The study finds that whilst there is evidence the participants hold pre-conceived ideas, a lack of relevant skills and knowledge as well as an unstructured implementation of the Parenting Assessment Manual 4.0, are both contributing factors. Furthermore, problematic multi-agency working and managerial influences impact on the overall outcomes for parents with learning disabilities and their families.
  • Exploring the staff development needs of junior academic middle managers in a Faculty of Health and Social Care during organisational change: A Bourdieusian perspective.

    Evers, Jean (University of ChesterUniversity of Chester, 2019-12)
    The aim of this study was to gain an in-depth understanding of the personal and professional staff development needs of junior academic middle managers in a Faculty of Health and Social Care during a period of change. The research was undertaken in the North West of England in a post-1992 University, following a reorganisation of the Faculty of Health and Social Care and introduction of new roles. The study adopted an action research methodology and a co-operative inquiry method, which consisted of a co-operative inquiry group of junior academic middle managers who were also co-researchers. The nature of co-operative inquiry is for co -researchers to engage in repeated cycles of reflection and action that generate changes to their professional practice. The study was conducted over a period of one year and during this time multiple data collection methods were utilised to triangulate the evidence. The research findings identified that multiple identities caused conflict between professional and academic roles, negatively impacting on junior academic middle managers during periods of change. During transition, some participants reported difficulty in adapting to complex political reforms, which caused dissonance between their actual and perceived roles in the field. The junior academic middle managers reported that the safe and trusting environment of the co-operative inquiry group enhanced their confidence and enabled them to learn in action and acquire a reflexive approach when undertaking their roles in the newly structured organisation. The study contributes to the existing literature regarding role identity of professional academics in higher education and offers new insights into transition during complex organisational change.
  • A phenomenological exploration of nursing students’ experience of raising a care concern in clinical practice

    Cooper, Elizabeth (University of ChesterUniversity of Chester, 2020-01)
    UK pre-registration healthcare students are expected to raise a care concern about unsafe situations whilst in clinical practice. The UK’s NHS is in the midst of a change to an open, honest and transparent culture which responds to a professional’s concern about patient care, to improve safety and prevent harm. Central to this change is improving the experience of registered healthcare professionals whose decision to raise a care concern is influenced by the organisational culture; this can create a difficult moral choice. The experience of nursing students who decide to raise a care concern has received little attention, and this study sought to explore this under-researched area. A literature review was undertaken which identified that the experience of nursing students who had raised a care concern had not been previously examined. To guide this study, Clarke Moustakas’ (1994) transcendental phenomenological methodology was used to explore nursing students’ lived experience of raising a care concern. Ten nursing students with experience of raising a care concern in clinical practice voluntarily participated in the study. Open interviews conducted between December 2016 and October 2017 were audio recorded and transcribed, exposing individual narratives of raising a care concern in clinical practice. The transcripts were analysed to produce a composite description which summarises nursing students’ lived experience, reflecting four themes or essences: 1) patient centred concern; 2) deciding how to act; 3) having emotional strength; and 4) feedback and support. These typify what it is like for nursing students to raise a care concern whilst in clinical practice. The findings were critically examined and suggest that compassion may motivate nursing students to act when faced with an unsafe situation, seeking to stop patient harm and suffering. Recognising this moral motivation, students described the relevance of emotional strength when dealing with the emotionally complex experience of facing difficult situations, with feedback and support providing comfort plus moral and emotional satisfaction. This study also explores the implications for professional practice, specifically the impact upon future teaching and learning approaches to facilitate nursing students’ ability to detect and act upon unsafe situations; providing listening opportunities to support students in clinical practice; and valuing nursing students who raise a care concern as role models and local clinical leaders. Recommendations include a new national campaign to improve the likelihood of nursing students raising care concerns and updating UK professional guidance.
  • Predictors of mortality and survival in type 1 diabetes: a retrospective cohort study of type 1 diabetes mellitus (T1D) in the Wirral Peninsula

    Akata, Eloho (University of ChesterUniversity of Chester, 2019-05)
    Background: The prevalence of T1D is rising, despite improvements in the management of this condition. It presents a risk of premature and excess mortality, which impacts survival and life expectancy. Aim: The study aim was to assess mortality, identify predicting risk factors for mortality and survival in T1D in the Wirral. A systematic review was done to establish present current evidence of all-cause and cause-specific mortality amongst T1D patients. Methods: A retrospective cohort study design, 1786 patients diagnosed with T1D extracted from the Wirral Diabetes Register (WDR). The follow-up period was between 1st of January, 2000 to 31st December, 2012. The primary outcome measured was all-cause mortality. Results: 1458 participants with T1D meet the inclusion criteria, after a follow-up period of 12 years, 113(7.75%) deaths were recorded. While the incidence rate was steady over the study period, the prevalence rate continued to increase over the study period. Significant predictors of mortality in this cohort were age of diagnosis, duration of diabetes, HbA1c,systolic blood pressure (SBP), diastolic blood pressure (DBP), and triglyceride levels. The predicting risk gender, age at diagnosis, duration of T1D, BMI, serum creatinine levels, SBP, total cholesterol, LDL, HDL, TC\HDL, and LDL\HDL showed a linear increase in mortality risk. IMD and DBP followed a U-shaped relationship with relative and absolute mortality, while HbA1c levels reveal a sinusoidal pattern with the highest risk of mortality at the levels ≤ 5.9% (41 mmol/mol). The risk of mortality for the predicting risk factors for this study ranged between 5% and 9%. Maximal risk of mortality of 9% was recorded in the predicting risks of smoking, BMI, SBP, and DBP. The risk of mortality of 8% was recorded for IMD, serum creatinine, total cholesterol, TG, LDL\HDL ratio, and TSH. The risk of mortality of 7% was recorded for the predicting variables of HbA1c, HDL, LDL, and TC\HDL ratio. The minimum risk of mortality of 5% was recorded for the predictor variable of the duration of diabetes. The significant predictors of mortality were the age at diagnosis, duration of diagnosis, systolic and diastolic blood pressure, HbA1c. The burden of mortality rest disproportionately with females who had higher relative risk of mortality of 4 times that of their male counterparts, however, the burden of premature mortality as recorded by the years of potential life lost was slightly higher in males (1797[53.6%]) as compare to females (1553[46.4%]). Of the 113 deaths recorded for the cohort that indicated a proportion of 7.75% of the total T1D patients, records for only 37 participants were retrieved. The principal cause of death in this cohort was malignancy-related 8 deaths (21.6%), this was followed by cardiovascular disease and sepsis, each having 6 deaths (16.2%) respectively. Cerebrovascular disease accounted for 5 deaths (13.5%). Death from diabetes complications (hypoglycaemia) was recorded in 1 patient (2.7%). There were marked reductions in life expectancy for this cohort. Life expectancy at 40 years for females was to an average age mortality of 66.2 years as compared to males 78.3 years. There has been improved survival for T1D in this cohort, 77.185 years [95% CI: 75.191 – 79.179] in males and 76.011 years [95% CI: 73.169 – 78.000] in females. The systematic review highlighted increased mortality in those with T1D as compared to the general population, females showed greater risk of vascular complications as compared to the males with T1D. 35 studies were included. Results showed all-cause mortality RR 3.73 (95% CI 3.19, 4.36) compared to general population, with gender specific mortality RR 1.17 (95% CI 1.06, 1.29). For cause specific mortality risk (overall and gender specific): cardiovascular v disease RR 3.48 (95% CI 3.14, 3.86) and RR 1.41 (95% CI 0.92, 2.17); renal disease RR 1.06 (95% CI 0.89, 1.26) and RR 0.63 (95% CI 0.38, 1.04); neoplasms RR 1.03 (95% CI 0.92, 1.16) and RR 1.18 (95% CI 0.75, 1.86); cerebrovascular disease according to gender RR 0.99 (95% CI 0.66, 1.48), and accidents and suicides according to gender RR 2.30 (95% CI 1.31, 4.06). Conclusion In conclusion, the study highlighted significant mortality risk in females as compared to their male counterparts; there has been progress in the survival of patients with T1D. However, life expectancy remains reduced as compared to those without the condition. Prevalence of T1D continues to increase, and the complex interplay of the predictor variables support the need for an individualised approach to care.
  • Queering Blackpool: An Ethnographic Study

    Owens, Allan; Moran, Paul; Eadon-Sinkinson, Helen (University of ChesterUniversity of Chester, 2019-11)
    This research explores the notion of identity in relation to drag queens in the seaside town of Blackpool in the North West of England. What I describe is how this complex form of identity is composed not only from the appropriation and cultural manipulation of gendered tropes, in terms of behaviours, dress, and attitudes; but how identity is also composed from the socio-cultural place of Blackpool within the Northwest of England; and from specific genres of entertainment as they manifest in this sea-side town, which suffers from a high level of deprivation. The research employs qualitative data collection methods to build an understanding of how identity is created whilst exploring the ethnographic structure and representation of the town of Blackpool which is reflected in the analysis of the film through an autoethnographic lens. It becomes autoethnographic as it is my personal reaction to the research. I wanted to analyse my findings in terms of a qualitative visual ethnography and critical reportage, which takes the form of a short film which was an appropriate way to present the visual and socio-cultural representations of the data. Blackpool’s identity has been shaped by its raucous history. Early examples of dancing, drunken behaviour and prostitution at the Raikes Garden in the 1870s are documented by Walton (1998) as well as fairground style attractions and a rising number of cheap drinking establishments to cater for the influx of holidaymakers; all of which were difficult to police. Advertising the resort’s entertainment attracted more working-class visitors creating a more downmarket holiday resort which continues to this day. The working-class history of the town gives the resort a particular kind of focus. It also means that the town is vulnerable; it is vulnerable to economic market change, problems of poverty, and unemployment. Therefore, this thesis seeks to discuss the question: how is Blackpool’s social history reflected in both the town and drag performance spaces? This thesis uses the theory of Bakhtin’s Carnival (1984) to highlight certain aspects of the film in order to present the research through an appropriate theoretical lens as well as appropriate supporting literature throughout. I felt it appropriate to use Bakhtin, since even at the level of a superficial joke, Bakhtin’s work is located in celebration, freedom, holiday and the superficial preoccupations of historic and contemporary Blackpool. More significantly perhaps Bakhtin was interested in how the world, in these contexts, can be turned upside down, and what it means for order and identity to be essentially forms of performativity, a theme central to my own work around identity and place with respect to Blackpool. Due to the nature and disclosure of some participants I decided to present the data through the form of a film. Through the initial interview process, it became apparent that some identities needed to be hidden as a means of protecting both the participants and their families as sensitive details were 11 discussed, however their stories still needed to be told. To both explore and mitigate the problems that I have mentioned, visual ethnography seemed to offer both a solution and an interesting way to convey meaning that would otherwise be lost in text. By presenting the data in this way I am creating characters. This becomes unavoidable, rather like the drag queen performers who create characters, therefore I am paralleling that. By creating the characters that are heard and deliberately filming various aspects of Blackpool, I was able to join both person and place to create a visual means that represents the journey and exploration that I went through as a researcher and which further presents the data, as self and other, in the most appropriate way. When I use the word ‘trans,’ I am referring to transvestites, transsexuals and transgender people. Throughout this written part of this thesis, I will refer to the visual aspect as ‘the film.’
  • ‘Being different’: realities of life experiences as constructed by persons with albinism in Nigeria

    Mabhala, Andi; Keeling, June; Buck, Gill; Keen, Adam; Olagunju, Adeolu (University of ChesterUniversity of Chester, 2019-08)
    In Nigeria, persons with albinism (PWA) continue to face a higher burden of health and social challenges in the society compared with the general population. PWA experience multi-faceted social injustices such as stigma, discrimination and exclusion from education, employment and social participation. These injustices are driven by the Nigerian society because of sociocultural perceptions and stereotypes associated with albinism which can be attributable to the lack of adequate understanding of the condition. This research aimed to understand how the realities of being a PWA in Nigeria could be conceptualised based on their life experiences to develop a substantive theory of their social wellbeing status. By adopting constructivist grounded theory methodology, forty-two in-depth interviews were conducted amongst eleven PWA. Analysis identified three categories each of which embodies the multiple realities of disadvantages and exclusion experienced within the home, schooling, working and social environments at different stages of life. The concept of ‘Being different’ emerged from these categories to offer a theoretical explanation of what it means to be a PWA in Nigeria. The realities of ‘being different’ constitute processual social injustices for PWA because of how the Nigerian society is socio-culturally and institutionally configured to magnify the limitations of albinism above the rights and social liberties of the individual. This research identified albinism as a disability and concluded that PWA are owed a moral and ethical obligation by the Nigerian society for them to be able to access the liberties and support necessary to secure their health and social wellbeing. The sustainable fulfilment of this moral and ethical obligation necessitates an inter-institutional collaboration and vigilance that should address the layers of injustices meted to PWA. This study adds an original contribution to knowledge by offering a theoretical concept to qualify the social status of PWA in Nigeria, and thus, could be useful to inform appropriate health and social care interventions.
  • Utilising a Bourdieusian lens to explore emerging health visitor practice education experiences within the context of the Health Visitor Implementation Plan

    Gidman, Jan; Taylor, Lou; Haydock, Deborah (University of Chester, 2019-05-14)
    The Health Visitor Implementation Plan (HVIP) (DH, 2011a) changed the recruitment criteria for health visiting and the way health visitor (HV) practice placements were supported. Several universities offered accelerated '2+1' programmes, where a graduate with a health related degree obtained accreditation of prior learning and completed pre-registration nurse training in two rather than three years. This was then followed by a one-year post-registration Health Visitor programme. This widening of recruitment afforded a unique opportunity to explore the experiences of 2+1 HV students, practice teachers (PTs) and mentors, and emerging practice education models within the context of the HVIP. Findings are considered through the lens of Bourdieu’s theory of practice. The study adopted an interpretive phenomenological design to gain a deeper understanding of the experiences of students, PTs and mentors. In-depth semistructured conversational interviews were undertaken with four HV 2+1 students, two PTs and two mentors. Interviews were recorded, transcribed and analysed using Interpretative Phenomenological Analysis. Findings viewed through a Bourdieusian lens indicate that policy change in the form of the HVIP affected the structure of the social field, resulting in a period of transition when some participants had difficulty adapting to the changed social context. Long arm models of practice education added to the complexity of the PT role, including the additional responsibility of overseeing numerous students and mentors. Mentors reported feeling under pressure, exacerbated by working in inexperienced teams; and frustration that their contribution to the HVIP was disregarded, compounded by a lack of opportunity for professional progression. Students undertaking different routes into nursing are affected by extrinsic views and this affects evolving habitus and enculturation. When students’ prior experience is valued, this strengthens the students’ perception of their ‘field’ position. Placement changes, particularly during consolidation, can be detrimental as they affect habitus formation and student learning and impact upon assessment processes. The research offers new insights into health visiting practice education and the impact of policy change on practice settings. The findings have implications outside health visiting in the current context of changes to nurse education and the introduction of the new NMC (2018b) standards for student supervision and assessment. New knowledge is offered with regards to the significance of transition periods, changing roles, and the potential impact upon the provision of student practice placements and those who support them. Recommendations are made for further areas of research, practice placement providers and HEIs.
  • An ethnographic study that explores the policy and cultural influences on the continuing professional development of nurses and their utilisation of computer technology in a community hospital in Uganda

    Gidman, Janice; Wilson, Frances (University of Chester, 2019-03-19)
    Through ethnographic fieldwork conducted in a hospital in rural Uganda, the study explores how continuing professional development (CPD) of nurses is supported through utilisation of information and communications technology (ICT), and how policy and culture can influence this process. The existing research literature raised three questions: what facilitates and restricts learning and using computer technology? What are the nurses’ views and experiences of using ICT? Is nurses’ professional development and how they utilise ICT influenced by policy and culture? The literature, drawn from international sources, is reviewed in chronological order to reflect the development of ICT and its use in health services and CPD. Policies and theories are analysed to gauge their relevance to the research aims and questions. These include Walt’s policy analysis theory; Hofstede et al.’s dimensions of national culture; Rogers’ diffusion of technology theory; Davies’ technology acceptance model; and theories of culture. These theories are synthesised into a model of influence. Early in the research, a macro study of Uganda was undertaken covering the political, economic, sociocultural, technological, legal and environmental (PESTLE) impacts on the ICT infrastructure, health and nursing. Spradley’s (1979, 1980) developmental research sequence (DRS) formed the methodological framework, providing a systematic and comprehensive approach to data collection and analysis. Its twelve steps were applied to participant observation and ethnographic interviews, offering a progressive approach to data analysis through domain, taxonomic and componential analysis. Spradley’s DRS enabled dimensions of contrast to be identified and the discovery of unique cultural themes. Four field visits took place between 2009 and 2012, each lasting two weeks. Participant observation was undertaken on each visit, and interviews and focus groups on the third and fourth visits, facilitating exploration of ICT developments, computer skills training, education and CPD. Informants expressed their views about cultural influences on technology development, and their knowledge of policies and how they impacted on ICT adoption and nurses’ computer skills development. The study makes a unique contribution to knowledge by analysing the influences of culture and policy on nurses’ CPD and utilisation of computer skills. Major findings include the significance of cultural themes amongst factors influencing ICT adoption, CPD and development of nurses’ computer skills. Knowledge of the local culture, as well as the underpinning theories, contributes to the successful construction of teaching strategies for this professional group. The impact of policies has been influential in building the national and local ICT infrastructure, but CPD and nurses’ computer skills have developed in the research location due to local capacity building rather than the direct impact of policies.

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