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Background: The purpose of this qualitative nursing study has been to understand the experience of death and dying in the emergency department of a hospital, through listening to the experiences of bereaved family members and nursing staff. Death and dying remain taboo subjects in society today and therefore people may come to the end of their life without having thought about what death and dying might be like and what it is to have a good death. Culturally, individuals are unprepared for death, and when death occurs in an emergency setting it is particularly shocking. Methods: A phenomenological study was planned, based on the existential phenomenology of Merleau-Ponty; and framed by the nurse theorist Hildegard Peplau. Eleven bereaved family members and eight registered nurses gave in- depth interviews describing their experiences and the interviews were analysed using an adaptation of the work of Thomas and Pollio (2002) and Hycner (1985), consistent with Merleau-Ponty's theories. Results: The study brings new understanding of what it is like to die in an emergency setting through new understanding of what the family members of the deceased person experience, aided by new understanding of the experiences of emergency nurses. Uniquely, the voice of the bereaved family member is heard. Conclusions: Recommendations for improvements in education, clinical practice, research practice and policy are made along with suggestions for further research to be carried out on this topic. A nursing model for end-of-life care, based both on the work of Peplau( Peplau, 1991 ) and on the work of the nurse theorists Ruland and Moore (Ruland and Moore, 1998; Zaccara et al., 2017) was devised for use in the Emergency Department.

Background: As a discipline, nursing espouses ideologies of inclusion, equity and valuing diversity. However, little is known about how these ideologies translate into clinical care. Pressure ulcer prevention is a routine aspect of nursing care; yet there is evidence of inequity in relation to patient assessment and clinical care, with a higher prevalence of pressure ulcers in people with dark skin tones. Despite limited literature being available surrounding the topic of pressure ulcers and skin tone diversity, it remains the responsibility of nurse educators to address contemporary issues and health inequity within the nursing curriculum to ensure that the teaching of pressure ulcer prevention is inclusive. Aim: The aim of the study was to critically evaluate the educational preparation of registered nurses in Higher Education institutions in relation to pressure ulcer assessment and identification, particularly focusing on skin tone diversity. Method: A sequential mixed method collective case study design has been applied. The first phase of the study, after the development of an observation and documentary analysis tool, assessed whether pressure ulcer identification and assessment in undergraduate nurse education programmes considered skin tone diversity through the analysis of educational material and teaching observations at five Higher Education institutions in England. The Higher Education institutions were recruited through a purposive sample, following ethical approval (University Research Ethics Committee Registration No: 171077). The preliminary findings informed the second phase of the study as per the requirements of a sequential mixed method study (Creswell, 2014). The second phase included semi-structured interviews with a nurse educator and focus groups with students at each of the previously selected Higher Education institutions. Informed consent was obtained before data collection and participants were informed that involvement in the study would not have an impact on either their employment or their educational programme. Findings: The first documentary analysis phase of the study confirmed all Higher Education institutes overwhelmingly directed teaching and learning activities about pressure ulcers towards people with light skin tones. Observation of teaching indicated all teaching sessions only contained brief, separate and superficial information on people with dark skin tones and pressure ulcers. There was no discursive language or awareness of colour or colour blindness. In the second phase of the study, classroom learning was predominately framed through a white lens with White normativity being strongly reinforced through teaching and learning activities. This reinforcement of White normativity was evidenced through four main themes: i) dominance of whiteness in the teaching and learning of pressure ulcers in undergraduate nurse education ii) the impact and implications of whiteness as the norm in pressure ulcer teaching on student nurses iii) the role of external inputs on the teaching and learning of pressure ulcers in on-campus undergraduate nurse education iv) suggestions for change in educational practice of skin tone diversity: improvements within the classroom. Conclusion: Nurses responsible for the design and delivery of teaching and learning experiences for students of nursing need to ensure meaningful teaching and learning experiences that facilitate future nurses to interrogate their complicity within a system of White dominance. Anti-racist pedagogy and the radical critique of all teaching and learning activities are needed to help explore, improve and meaningfully include skin tone diversity and inclusivity in nurse education.

Background: The shortage of critical care nurses is a global concern. Although all areas of nursing are affected, critical care areas are especially vulnerable to retention problems. Nurse retention in critical care areas impacts nursing shortages, staff morale, productivity, patient safety, and quality patient outcomes. The issue of nurse retention in critical care areas is evident; however, research into the factors that influence nurses' intention to leave adult critical care areas is limited. Exploring factors that influence nurses' intention to leave adult critical care areas is therefore important and may help in the development of strategies to improve nurse retention, reduce critical care nursing shortages, and thus improve the quality of patient care. Aim: To examine factors that may influence nurses' intention to leave adult critical care areas and to explore critical care nurses' views and experiences about their working conditions. Method: A sequential explanatory mixed-method design was used. The main purpose was to use qualitative data to expand on the findings generated using a quantitative approach. Data were collected in two phases from November 2017 to April 2018. An adapted version of the Nursing Work Index-Revised (NWI-R) tool was used in phase one to survey all nurses currently working in adult critical care areas across England; 345 surveys were returned. Data were analysed using chi-square tests, t-tests, factor analysis and logistic regression analysis to determine factors that were associated with nurses' intention to leave. Content analysis was carried out to analyse qualitative comments collected in phase one in response to the three intentions to leave questions. Semi-structured telephone interviews were carried out with a purposive sample of critical care nurses in phase 2 to gain in-depth accounts of the factors identified in phase 1 and to explore possible solutions to retain nurses. Qualitative data were collected from 15 participants. A framework approach was used to analyse interviews thematically. Data from both phases were integrated using a joint display and narrative weaving approach in phase three. Results: This study has successfully filled the gaps identified by the literature review including quantifying the data concerning the number of nurses who expressed intention to leave their current job and/or profession in the next one to five years. Quantifying the data regarding nurses' intention to leave is significant as this will hopefully attract the attention of critical care nurse leaders to take notice of this issue and develop strategies to reduce turnover intentions and thus reduce nursing shortages and high turnover. This study has explored the issue of critical care nurses' retention holistically rather than exploring a single factor associated with nurses' intention to leave contrary to previous studies. To our knowledge, this is the first mixed-method study that has explored factors influencing nurses' intention to leave adult critical care areas and hence, not only identified the factors that are significantly associated with nurses' intention to leave but also explained what these factors mean to nurses and why they influence their intention to leave. This detailed insight will make it easier for nurse leaders and policy makers to develop strategies in reducing nurses' intention to leave. The following themes were identified following the integration of findings in phase one and phase two: promoting nurse autonomy and a culture of shared governance, providing a supportive work environment and a system of wellbeing, enhancing workforce relationships and multidisciplinary collaboration, demanding a structured education and development programme and career progression opportunities, feeling demoralised due to the lack of appreciation and acknowledgement for their specialist knowledge and skills, providing flexibility and maintaining work-life balance when managing the roster, acknowledging nurses' level of experiences when managing teams and experiencing stress and anxiety because of workforce shortages. Discussion/Conclusion: Overall, the findings of this study have identified several key operational and management issues associated with critical care nurses' intention to leave such as providing educational and professional development opportunities, supportive work environment, promoting nurse autonomy, maintaining work-life balance while managing the roster and workforce shortages. Additionally, this study highlighted some of the more unpleasant aspects of the critical care nursing work environment within critical care and associated workforce misbehaviours. Some of these negative aspects of the critical care nursing culture included judgemental attitudes towards other colleagues; remarks that were anti-intellectual, racist, or ageist remarks towards others; and non-supportive, or even bullying behaviours directed at the junior workforce. Another interesting finding was the feeling among the critical care workforce that they should receive preferential treatment in relation to those employed within other non-critical care areas, such as financial incentives and accelerated career pathways on account of their specialist knowledge and skills which necessitate the completion of additional courses. Another important contribution of this study was the reinforcement and validation of the theories of intention to leave that were developed previously but which have not been acted upon since. Furthermore, based on the findings of this study, a detailed account of recommendations has been provided which will help critical care nurse leaders and policy makers in developing strategies to reduce critical care nurses' intention to leave and thus high turnover and nursing shortages within the adult critical care settings.

Aim: To understand the role of patient involvement in the promotion of hand hygiene among nurses in the hospital setting. Methods: This qualitative PhD thesis is comprised of two studies; focus group discussions with nurses and interviews with patients. In the first study, focus group discussions (n = 7) were completed with nurses from Jordan and the UK (n=36) to explore nurses' views and experiences with patient involvement in hand hygiene. Data from nurses were analysed using thematic analysis. In the second study, semi-structured telephone interviews were completed with patients from Jordan (n = 21) to understand their experiences of asking nurses to wash their hands. Data from patients were analysed by critical incident analysis resulting in the identification and analysis of 116 critical incidents. Results: The analysis of the focus group and critical incident discussions resulted in four overarching themes. Although both nurses and patients acknowledged the patients' right to ask, both groups reported concerns that asking about hand hygiene could have an adverse impact on the nurse-patient relationship. Patients reported that the promotion of hand hygiene was not only offensive and upsetting for nurses, but also embarrassing for patients. Patients reported negative reactions from nurses when promoting handwashing, and these encounters became stressful and confrontational though both groups indicated that this could be mediated if the patient asked in the 'right way'. It is not clear what the 'right way' might be. Discussion: Patients are likely to encounter confrontation if they prompt hand hygiene unless they do so in the 'right way'. Patients seem to be discouraged from taking an active role in their care and this needs to be considered when planning patient involvement strategies. Conclusion: Findings from this study show that patients are expected to be passive, grateful and remain silent when observing noncompliance to hand hygiene practices among nurses. It could be that hospitals have not predicated the negative encounters or else they would not encourage patients to remind nurses to wash their hands. Therefore, more work needs to be done to ensure that patients can speak out and raise concerns without fearing the negative consequences when asking nurses to wash their hands. Nurses suggested a need for a new hospital culture of patient involvement in ensuring patient safety through the promotion of hand hygiene compliance.

There is a continuing interest in spirituality, a fact that seems to fly in the face of claims that UK society is becoming more secularized. Although there has been increased interest and research in spirituality in counselling, there is little specifically concerned with psychodynamic counselling. This thesis argues that incorporating spirituality into psychodynamic practice, in response to client demand, may be harder than for many other counselling approaches. This is because of its roots in psychoanalysis, a field that has been consistently resistant to validating the spiritual dimension. This study explores how counsellors understand spirituality within the theoretical framework of psychodynamic counselling, and employs a narrative methodology to consider how they understand their attitude to impact on their practice. A key finding of the study is that there is an absence of spirituality within the psychodynamic profession, whose structures and training provides little impetus or encouragement to explore it. This research shows the complexities in working with spirituality and the need to work at the boundaries of practice. Because of the complementary nature of spirituality and psychodynamic counselling, this study demonstrates that spirituality is always a possibility in the work. As a result, the research identifies the need to increase professional discourse, from the start of counsellor training, in an area consistently important to clients, so that understanding can be shared and counselling practice in this area more fully understood.