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This study outlines a hermeneutical journey which investigated the contested concepts of intuition, reflection, thinking and knowing-in-action. Situated within the 'world' of nurses and their patients, participant observation enabled the lived experiences and narrative accounts of four registered nurses to be explored and analysed. When the traditional methodological frameworks associated with ethnography and participant observation proved inadequate, the author drew upon insights from postmodernism, discourse analysis. Nightingale and Foucault to develop and evaluate the study. Three significant points emerged. First, an epistemological discourse of the grey/rainbow is encountered. This discourse acknowledges that 'all cannot be said'. Second, it is argued that intuition refers to a signifying process which enables the practitioner to indicate a particular state of being of Self to Other. Fieldwork evidence suggested that when registered nurses 'know' in practice, they utilise a range of searching activities which orientate the Self/Other, thereby enabling plurisensorial, embodied knowing/doing to contribute to their judgements. This process, named actioning, may be accompanied by silencing and a nursing equivalent of regard (gazing). Finally, nursing is portrayed as a bricoleur activity which predates the 'post modem', incorporates the modem, and struggles to express itself within the constraints of a Cartesian Discourse.

The decision to request an assessment for dyslexia whilst at university is often one of the most complex decisions a student has to make. It involves careful examination of the implications; balancing any perceived benefits, against actual or potential disadvantages. Despite this, very little is known about factors which influence students making this decision. A two-phase exploratory qualitative approach was selected to identify how many university students consider being tested for dyslexia, how they proceed and reasons behind this. Phase 1 consisted of an online survey available to all students registered at one UK University. Data was obtained from 674 students at all stages of their educational journey, across 8 different faculties, including 533 on Undergraduate; 54 on Post-graduate taught and 85 on Post-graduate research programmes. Of these 310 students had considered being assessed and explained why they had chosen not to go ahead. In depth interviews with 6 of these students, and a further 5 who had been assessed then provided a greater understanding of the factors involved. Results revealed a myriad of reasons, with some considered pivotal. Students had to have reached a tipping point before they were sufficiently motivated to seek an assessment. Reaching this point was largely determined by their academic self- concept and how well they perceived that they were doing. When students did acknowledge that they were struggling, often after prompts by others; whether or not they recognised dyslexia as a possible explanation was influenced by their understanding of the condition. This in turn was heavily influenced by how they saw it manifest in others. All of the students who had been assessed did so following a prompt by a member of academic staff. There are clear implications for educational practice arising from this research, which need to be supported by policy change. These focus on the need to enhance understanding of dyslexia in both students and academic staff. Strategies to raise student awareness, alongside more in-depth staff development initiatives are proposed. There is also a need for future research to explore in detail factors influencing specific professional groups and postgraduate students.

Articulating what nursing is and what nurses do, has been a challenge since the creation of the profession. This research draws on technology to solve the issue of revealing and investigating the tacit nature of nursing through the concept of the nursing gaze. Drawing on the visual attention of nurses, this two-phase experiment identified that the nursing gaze is complex but can be identified with eye tracking and verbal utterances. Both phases of the study utilised videos of simulated nursing practice that acted as the stimulus for viewing. The practical challenges of tracking eye movement and verbal utterances when stimulus is video was identified and led to the development of Gaze-to-Text to solve these. This novel method drew on ethnographic techniques to combine both eye movement and verbal utterances of novice identifying the tacit nature of the gaze. Concurrent eye tracking and recording of the viewers ‘think aloud’ commentaries led to the identification of eight verbal performative signifiers used by nurses to judge the behaviour and actions. Analysis of both novice and expert nurse’s eye movement demonstrated areas of convergence and divergence and when combined with the verbal utterances, allowed conclusions to be drawn about the cognitive and perceptive processes involved in the nursing gaze. The findings of the study have implications for developing novice nurses through the articulation of expert nurses gaze. The method of Gaze-to-text offers potential for understanding visual attention and the tacit elements of professionals in other fields.

Background: Job satisfaction is a vital concept in nurse retention. Two reasons are thought to contribute to the severe scarcity of nurses in Saudi Arabia: (a) the nursing profession is considered a low status profession with associated negative public perceptions; and (b) cultural barriers that restrict female access to education and employment, particularly in jobs that require contact between genders. The substantial shortage of Saudi nurses in the Saudi Arabian health system has led to a heavy reliance on foreign nurses. This historical dependence on massive numbers of non-Saudi nurses from countries around the globe, and a fragmented approach to their recruitment, has led to inequalities in the remuneration and treatment of nurses. The multicultural nature of the workforce and its potential impact on job satisfaction renders an investigation into the role of nationality a research priority. Aim: To examine whether nationality has an effect on job satisfaction and 'intention to leave' among nurses in Saudi Arabian government hospitals. Methods/Design: A design of mixed quantitative and qualitative methods was utilised in this study. The quantitative element utilised a survey approach; this approach consisted of McCloskey and Mueller's Satisfaction Scale, which was used to measure nurses' job satisfaction across eight types of satisfaction. Additional questions addressed their intention to leave and demographic variables. The qualitative approach utilised semi-structured interviews to further explain any identified associations. The study was conducted in three major government hospitals in Saudi Arabia. The study sample consisted of 747 participants who completed the questionnaire, of whom 26 also participated in semi-structured interviews. Data were collected over a nine-month period between May 2014 and February 2015.

For the period 2012-2016, the Thai 11th National Health Development Plan focuses on the accessibility and equity of mental health care by using community collaborations in order to ‘strengthen and empower the sub-district health system’. In reality, demands and supply should be balanced, based on available resources. Therefore, including the patients’, caregivers’ and health care providers’ perspectives for schizophrenia care improvement is considered helpful to gain an in-depth understanding of the community mental health nursing care situation; this endeavour is aimed at improving mental health nursing practices, based on available resources. There has been no previous research exploring stakeholders’ perspectives of care at the primary level in the rural Thai community. This qualitative study aims to provide an in-depth understanding of both service users’ and service providers’ views. Semi-structured interviews were carried out with 40 participants within three groups, which involved patients with schizophrenia, their caregivers, the primary care staff in the community, and the supervisory teams in the community and psychiatric hospitals. Interviews were transcribed verbatim, translated into English and analysed using thematic analysis. Each group of participants was analysed individually to provide specific and integrated themes. Three key areas relating to all three groups are 1) the lived experience, 2) the importance of medication and 3) the service and support needs. The results illustrate the complexity of the Thai situation, due to poverty within a rural environment and conflicting views regarding the need to move away from a biomedical model of care. The results will be used to inform community mental health nursing practice and education in Thailand.

The purpose of this study was to improve the care of children with VSD in rural Thailand. Based on the literature review, these children experienced long waiting times or surgery and had difficulty in gaining or maintaining optimal weight prior to surgery. An ethnographic approach was used to explore and understand the aregivers’ problems in their cultural context; especially the experiences of how the amilies managed the care of their child, in order to overcome the issues of gaining or maintaining optimal weight prior to surgery. Ten family case studies resulted from semi-structured interviews, field notes, observations, and photographs from the ten main caregivers of children with VSD. Ten health professionals who dealt with these children were interviewed to ascertain any differences in perspective between the professionals and the caregivers with respect to nutritional management. Data were collected between January and May 2012 in a egional hospital and at the homes of the participating caregivers. A thematic approach was used to analyse the data. The triangulated findings generated themes indicating hat both health professionals and caregivers had insufficient knowledge in taking care of children with VSD in rural Thailand, who were waiting for surgery. The key issues elated to the caregivers’ insufficient knowledge were the limited knowledge of health professionals, inadequate resources at the clinic and the clinical environment did not provide useful information. Furthermore, some of the knowledge the caregivers used was inappropriate for supporting weight gain in their child. Drawing on the literature and findings, the content for nutritional preoperative information package for the aregivers to help enable their child to gain or maintain optimal weight prior to surgery has been designed. The findings suggested that, particularly in the rural areas, any written materials to support the caregivers should be designed for those who have a eading age of at least primary school level.

Using Casebook Ethnography, nine registered Adult Nurses were observed and interviewed to explore the ways in which they undertook their daily work and the place of reflection in that. The participants were employed in one of two units; a surgical breast care and an acute palliative care unit, both of which were in a large National Health Service trust hospital in central England. Data collection was illuminated by the researcher’s reflective journal. The data collected, rather than simply describing reflective practice, led to wider and more broadly focussed findings which, when analysed, generated one central theme - Communication, Interaction and Discourse and three linked associate themes - Being and Caring, Practical Action, and Knowing. These themes were considered in the light of the key literature around nursing practice and reflection. The findings point to a new understanding of contemporary nursing practice, which illustrates ‘what our kind does’, amongst the groups of participants in order to deliver patient-focussed care. This practice was directed towards working with colleagues who shared the same values and understandings, and who used these shared beliefs to adapt their practice to achieve individualised and exquisite care. As they communicated and interacted with one another, the participants went about their work with attention to empathy and caring, articulated as a common humanity with their patients. They prioritised action where patient need was clear, and used a form of knowledge that was negotiated and validated within a community of practice. As they maintained a dialogue in their teams, the participants developed a sense of their professional identity and of who qualified as ‘our kind’. The implications of this study are that a fuller understanding of how nurses work in contemporary practice will inform the preparation and continuing professional development of nurses and the ways in which effective clinical leadership may be implemented.

For over 30 years, the assessment of the clinical competence of student nurses has been the subject of much theoretical debate, yet the definition of criteria based on observable indicators of competence remains problematic. In practice, however, different assessors will judge and agree, relatively quickly, whether a student is competent or not; whether they have got ‘it’. Articulating what ‘it’ is, is difficult; although ‘it’ appears to be collectively, yet tacitly, understood. These judgements provide the key to the definition of competence. This research solves the dilemma of revealing and investigating these tacit understandings through the video analysis of students in simulated practice. The findings of four initial exploratory studies confirmed that competence is an example of tacitly understood behaviour and identified the limitations of traditional research methods in this context. The practical challenges of analysing video were highlighted, leading to the development of Video-View-Point to solve these problems and to reveal the tacitly understood behaviours. This innovative hybrid research method combines analysis of multiple ‘Think Aloud’ commentaries with the ability to ‘point’ at the subject of interest. The analysis is presented as a time-stamped multimedia dialectic, a visually simple yet sophisticated collage of data which reveals relevant behaviours, including those which are tacitly understood. A bespoke software tool (BigSister) was designed to facilitate the data collection, and was tested against the most similar commercially available technology, an eye tracker. The test of Video-View-Point successfully revealed four tacitly understood indicators of competence: communication, processing clinical information, being in the right place, and being proactive. Video-View-Point offers huge potential for behavioural analysis in other domains.

Nursing scholarship and healthcare policy set an expectation that nurses should think about patients as persons. Nevertheless, the literature reveals that critical care nurses can struggle to perceive patients as persons, and thus suggests they may think about patients in different ways. This thesis presents the findings of an ethnographic study undertaken within one critical care unit in the United Kingdom which examined how critical care nurses do think about patients. A purposive sampling strategy recruited 7 participants representing both experienced and inexperienced critical care nurses. Data were collected over a period of 8 months during 2006 to 2007, and primarily comprised the field notes from 92 hours of participant observation supplemented by 13 tape recorded interviews. Data analysis was influenced by Foucault and Goffman and adopted the perspective of linguistic ethnography. Analysis revealed that all participants thought about patients in seven distinct ways: as ‘social beings’, as ‘valued individuals’, as ‘routine work’, as a ‘set of needs’, as a ‘body’, as ‘(un)stable’ or as a ‘medical case’. Accounts of participants’ practice revealed that they had a tacit understanding that these different ways of thinking related to aspects of one coherent whole, but no one way of thinking could be characterised as thinking about this ‘whole person’. Nurses could only think about one aspect of the patient at a time. Nurses’ practice was not guided or explained by their thinking about patients as persons, but rather expert practice was characterised by nurses’ fluid and appropriate movement between different ways of thinking about patients. When participants talked about their practice it was evident that these nurses could only legitimately talk about themselves as giving care to persons. Participants characterised some of the ways in which they had to think about patients as impersonal, and this actively hindered these nurses from describing or reflecting upon elements of their practice. There is therefore conflict and dissonance between nurses’ expectation that they should think about patients as persons, and the fact that delivering nursing care requires them to think about patients in different ways. The development of future critical care nurses will require practitioners and educators to recognise that nurses think about patients in different ways, and that expert practice is characterised by the clinical wisdom which enables nurses to think about patients in ways which are appropriate to the moment. Nurse scholars and educationalists should therefore avoid claims to a unique professional knowledge base which suggest to nurses that some ways of thinking are always inappropriate or inherently reductionist. Instead, there is a need for scholars and policy makers to articulate a vision of person centred care clearly, and in ways which avoid constructing dissonance between nurses’ ideals, and the ways in which they do and must think about patients.

This thesis describes a three-stage project using a qualitative case study approach. It explores in what way the features of Army life affect the daily lives of Army parents, how aspects of Army life influence the decision-making of mothers, and what support Army mothers expect when their child is unwell after their primary health care centre has closed (called the out-of-hours period). The study was conducted within an Army garrison in England. It occurred during an intense period of overseas operational deployment that left mothers as temporary lone parents for many months. Out-of-hours service provision had changed from an Army clinic within walking distance to an NHS provider located over thirty miles away. Phase One, using focus groups with 24 parents, identified how Army life affected parents and what their expectations were for health care provision in the out-of-hours period. During Phase Two, seven of these parents were interviewed to explore the themes identified in the previous stage in greater depth. Phase Three involved interviews with a further seven mothers who had accessed the out-of-hours clinic when their child had been unwell, to investigate the decision-making process that led to a consultation with a health professional. This study provides a rich and detailed description of how disruption, mobility and enforced separation affect parents living with young children within a garrison in England and the coping strategies that mothers used. It is distinctive as it theorises that emotional vulnerability caused by anxiety and fear during military enforced separation challenges a mother’s fundamental sense of belonging. An algorithm developed from the findings demonstrates that a partner’s presence influences whether the mother calls health care services as a first or last resort. Thus, it makes an important contribution to the development of both civilian and military knowledge regarding a mother’s decision-making behaviour and her expectations for care when her child is unwell, particularly when a lone parent

This research investigates the barriers and drivers of eLearning for healthcare professional students in rural Thailand. An initial desk study was undertaken to investigate the factors that had an impact on eLearning within a professional healthcare environment. This was followed by a pilot study in a university in rural areas of Thailand. The results from the investigation led to a model being created to identify the barriers and drivers for implementing eLearning programmes in rural Thailand. This research explores the challenges of eLearning within four domains (IFPC); infrastructure (I), financing eLearning courses (F), university policy (P), and cultural diversity (C). The research utilised mixed research methods to identify the impacts of eLearning; employing both quantitative and qualitative methods. The participants of this research included healthcare professionals associated with the eLearning environment within rural areas in Thailand. The fieldwork data from both quantitative and qualitative methods were analysed assisting by SPSS software and Nvivo software. The results and findings demonstrated that the IFPC domains impact on the uptake of eLearning for healthcare professionals and healthcare professional students. The results of statistical testing corroborated that healthcare professional students with their own computers perceived that eLearning was useful to their professional development. In addition, it showed that universities’ policies on eLearning affected the use of the eLearning infrastructure, the participants’ motivation to undertake eLearning courses and that eLearning course-uptake was affected by both healthcare professionals’ motivation and their ability to use a computer. The subject of the financing of eLearning course was directly correlated to the level of computer skills held by the healthcare professional students and their attitude towards their own use of computers. The results identified how the elements of the IFPC model were related to each other and affected the implementation of eLearning programmes. It is hoped that these findings will make a significant contribution by informing lecturers about online teaching material, course delivery and design. They will also inform policymakers when considering budgets, plans and requirements for supporting healthcare professional students undertaking eLearning in rural Thailand. In particular the results will provide useful lessons for healthcare professionals undertaking similar programmes in other developing countries.

This thesis explores the concept of reflection as it exists within the discipline of nursing. It focuses on the social construction of reflection through a post-registration, palliative care programme in the UK. An interpretive ethnographic approach was used to study organisational, contextual and cultural issues, explore teaching and learning interactions and learn more about reflection from student and teacher participants. This was achieved by using ethnographic tools to collect data from observations of teaching and learning; interviews with participants; and extracts from programme documentation and reflective learning contracts. The thesis portrays a programme culture committed to reflection as a valuable way of helping nurses make sense of their practice and make a difference to it. Reflection in order to make sense of practice was constructed by participants as a way of ‘being’ rather than simply ‘thinking’ or ‘doing’, since it intertwined propositional, affective and active elements. This process of reflective ‘being’ within the study was apparently associated with a humanistic approach to nursing, which emphasises the importance of actively using and expressing oneself in order to care for people. Reflection took place through verbal and written dialogue about practice and required both support and challenge. This was achieved through collaborative facilitation from teachers, clinical supervisors and peers, in addition to largely positive education and clinical environments which supported the development of reflection. It was through this reflective education that the programme was educating nurses to learn a language through which to communicate and liberate their practice knowledge with ‘confident, authentic’ voices. Thus learning a language of reflection was important to nurses in order to: articulate their professional knowledge to others; develop meaningful practice; liberate their learning, and consequently attempt to make an active, positive difference to patient care. In conclusion, by adopting an approach focused on exploring reflection through its social construction, this study has contributed further knowledge about nurses’ use of the concept and what it means to them. The thesis argues that there is an inextricable link between how nurses construct the meaning of reflection and their concepts of nursing. It also indicates the significant influence of skilled, collaborative teachers and both education and clinical environments to the use and development of reflection. In addition, it contributes further understanding to the process of teaching and learning about reflection including: support and challenge through facilitation; the necessity of dialogue for reflection; and the ultimate requirement for nurses to find ways to communicate their practice in ways that have authenticity and currency in modern healthcare.