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This paper addresses a central paradox that affects the nature of the student experience in the UK. On the one hand, the marketisation of higher education, with its associated emphasis on performativity indicators, may be seen to have reduced students to numbers, with the attendant consequence that the affective domain of studying and learning has been lost. On the other hand, there is more attention given to student feelings than was ever the case in the past and questions about student satisfaction have become more prominent. This paper will explore this paradox using empirical data gathered from a longitudinal study of ‘non-traditional’ students at one ancient university in Scotland. We indicate the ways in which the tension between the technicist spaces of the neo-liberal university and its empathetic, caring spaces are mediated by students as they make their way through their degrees. We argue that caring relationships with staff are of central importance to students’ well-being and success at university, and that students actively seek to construct support when and where they need it.

Aims and Objectives: to undertake an analysis of UK national daily newspaper coverage of accident and emergency treatment targets, in order to understand if the media could be seen to be creating a scandal. Background: Emergency Department treatment targets have become common in developed countries. In the United Kingdom (UK), hospitals are required to treat and discharge patients within four hours, and statistics are published daily. Breaches of targets are regularly reported by the UK print media. Design: exploratory research of tabloid newspaper articles that reported on four-hour treatment targets in the UK during a seven-month period over the winter of 2014-15 (n=1,317). An interpretivist thematic approach was utilised during analysis. Results: The main ‘problem’ identified by newspapers was the failure to meet the target, rather than negative effects on patient care (where they existed). Proposed solutions were diverse. Many articles did not describe who was to blame for the failure. Conclusion: We conclude that the media created a feeling of scandal, and hypothesise that this is related to political reasons and the availability of data on a daily basis. Relevance to clinical practice: it is important for nursing staff to understand the influence of the media on patients and how stories are reported.

IntroductioneHealth strategies targeting health-related behaviour often incorporate persuasive software design. To further engage patients with their overall health management, consumer-facing web portals may be integrated with data from one or more care providers. This study aimed to explore effectiveness for healthier behaviour of persuasive design characteristics within a web application integrated with the primary health care electronic record; also patient and general practitioner (GP) preferences for future integrated records.MethodsMixed methods study within the Consumer Navigation of Electronic Cardiovascular Tools randomised controlled trial. Participants were patients with moderate-high risk of cardiovascular disease, and their GPs. Survey and web analytic data were analysed with descriptive statistics. Interview and focus group transcripts were recorded, transcribed, coded and analysed for themes.ResultsSurveys (n = 397) received from patients indicated improved medication adherence (31.8%); improved mental health and well-being (40%); higher physical activity (47%); and healthier eating (61%). Users of the interactive features reported benefiting from personalised cardiovascular disease risk score (73%); goal tracking (69%); risk factor self-monitoring (52%) and receipt of motivational health tips (54%). Focus group and interview participants (n = 55) described customisations that would increase portal appeal and relevance, including more provider interaction. Of the GP survey respondents (n = 38), 74% reported increased patient attendance and engagement with their care. For future integrated portals, 94% of GPs were in favour and key themes among interviewees (n = 17) related to design optimisation, impact on workflow and data security.ConclusionIntervention features reflecting the persuasive design categories of Primary Task support, Dialogue support and System Credibility support facilitated healthier lifestyle behaviour. Patients valued customisable functions and greater patient-provider interactivity. GPs identified system challenges but saw advantages for patients and the health care relationship. Future studies could further elucidate the persuasive design principles that are at play and which may promote adoption of EHR-integrated consumer portals.

Background Personal asthma action plans (PAAPs) have been guideline recommended for years, but consistently under-issued by health professionals and under-utilised by patients. Previous studies have investigated sub-optimal PAAP implementation but more insight is needed into barriers to their use from the perspective of professionals, patients and primary care teams. Methods A maximum variation sample of professional and patient participants were recruited from five demographically diverse general practices and another group of primary care professionals in one Scottish region. Interviews were digitally recorded and data thematically analysed using NVivo. Results Twenty-nine semi-structured interviews were conducted (11 adults with asthma, seven general practitioners, ten practice nurses, one hospital respiratory nurse). Three over-arching themes emerged: 1) patients generally do not value PAAPs, 2) professionals do not fully value PAAPs and, 3) multiple barriers reduce the value of PAAPs in primary care. Six patients had a PAAP but these were outdated, not reflecting their needs and not used. Patients reported not wanting or needing PAAPs, yet identified circumstances when these could be useful. Fifteen professionals had selectively issued PAAPs with eight having reviewed one. Many professionals did not value PAAPs as they did not see patients using these and lacked awareness of times when patients could have benefited from one. Multi-level compounding barriers emerged. Individual barriers included poor patient awareness and professionals not reinforcing PAAP use. Organisational barriers included professionals having difficulty accessing PAAP templates and fragmented processes including patients not being asked to bring PAAPs to their asthma appointments. Conclusions Primary care PAAP implementation is in a vicious cycle. Professionals infrequently review/update PAAPs with patients; patients with out-dated PAAPs do not value or use these; professionals observing patients’ lack of interest in PAAPs do not discuss these. Patients observing this do not refer to their plans and perceive them to be of little value in asthma self-management. Twenty-five years after PAAPs were first recommended, primary care practices are still not ready to support their implementation. Breaking this vicious cycle to create a healthcare context more conducive to PAAP implementation requires a whole systems approach with multi-faceted interventions addressing patient, professional and organisational barriers. Electronic supplementary material The online version of this article (doi:10.1186/s12875-015-0352-4) contains supplementary material, which is available to authorized users.

Background: low back pain (LBP) is a major cause of work absence. Assisting individuals back into work is an important part of rehabilitation. Objective: to explore the experiences of individuals returning to work after an episode of sickness absence due to LBP. Participants: Five women employed by a UK University who had returned to work. Method: in this qualitative study, participants underwent semi-structured interviews about their experiences. The transcripts were analysed using interpretative phenomenological analysis. Results: two primary themes emerged 1) perceived pressure to return to work and 2) strategies employed to relieve the pressure to return. Pressure to return to work arose from a number of sources including guilt and a personal work ethic, internally, and from colleagues and management, externally. This pressure led to the individual employing a number of strategies to reduce it. These ranged from a simple denial of health concerns and decision to return to work regardless of their condition, to placing the responsibility of the decision not to return to work onto a significant other, such as a family member or health care professional. Cconclusions: individuals returning to work with LBP experience considerable pressure to return and use a range of strategies to mediate that pressure.

Working models of attachment are internal depictions of self relative to others and have been described in terms of two dimensions: (1) attachment avoidance and (2) attachment anxiety. An exploratory qualitative study was carried out to build understandings about women with Turner Syndrome (TS) and the psychosocial impact their infertility has upon salient relationships. In one-to-one semi-structured interviews, five women with TS were asked: How do you perceive your womanhood and infertility status has affected your relationships with: (1) the opposite sex, (2) siblings and (3) peers? In opposite-sex relationships, infertility status was found to arouse fear of ending up alone and anxiety over engaging in romantic relationships. In sibling relationships, jealousy was expressed in relation to disparity with sister(s) more natural maturation to womanhood, and, within peer relationships, consequences from divulging infertility status created attachment avoidance with friends. Further investigation in this area is merited.

Purpose: this paper aims to critically explore the consequences of how Scotland interprets the UK Misuse of Drugs Act (1971). Scotland prosecutes 24 per cent of people found in possession of illegal drugs for drug “dealing” compared to less than 15 per cent in England and Wales and less than 16 per cent in Northern Ireland.Design/methodology/approach: the paper provides a narrative review in the context of the background of the economic and social costs of illegal drugs in Scotland and compares this with the UK and Northern Ireland.Findings: the explanation for such a wide disparity in numbers of dealers between these countries proposed is that the Scottish police force is comparatively more successful at persuading courts that small quantities of drugs rather than for personal use are in fact for onward sale or supply to others.Practical implications: the police in Scotland have a network of specialist drug units in which officers make decisions in the absence of benchmarks against which to judge quantities of repossessed drugs. Taking this approach, a devolved Scotland's commitment to drug prohibition has resulted in some very curious differences in classifications of prosecutions compared to other countries.Originality/value: the paper explores the consequences of how Scotland deals with the use of illegal drugs and the economic and social costs.

Educators in healthcare face significant challenges trying to improve interprofessional teamworking skills, with a lack of clarity on how to teach and evaluate such skills. Previously, the team objective structured clinical encounter (TOSCE) has been reported as a teaching and assessment tool, but it has been used primarily in homogenous groups of undergraduates. An interprofessional team of educators set out to evaluate the TOSCE as a teaching intervention amongst a large interprofessional group of postgraduate nurses and midwives. After the TOSCE, 83% of participants reported that they were more aware of potential weaknesses in teamworking and 60% felt more able to work in a team. Mean Likert scale ratings were 4/5 for usefulness, enjoyment and relevance. The TOSCE is a feasible tool for teamwork skill assessment in the demanding postgraduate interprofessional setting and requires further investigation to ascertain its potential for formative and summative assessment of skills.

A demographic survey of London sex-workers established age, nationality, alcohol/drug use, physical/mental health concerns and whether trafficked or optionally migrated into the industry. There are overt differences between sex-workers—implications for police, health and social workers are that welfare services tailor care to meet individual needs within this population.

Nurse education is characterised by dissonance, ambiguity and uncertainty. Such a context makes demands on the educator’s authenticity or sense of self. This paper reports an attempt to provide a space where dissonance, ambiguity and uncertainty could be held, tolerated and examined and where authenticity could be recovered or developed through the practice of artistry. Three art workshops were offered to 8 nurse educators over a period of three months. Each of the participants and the co-facilitator were subsequently interviewed. All welcomed the opportunity to find meaning in their practice and to be listened to in a climate of empathy, acceptance and congruence. They undertook novel activities that allowed for discovery and surprise. They explored their sense of self and coined fresh metaphors to communicate their experiences. The paper argues that there is room for approaches to academic staff development that go against the mainstream.

PurposeWithin maternity hospitals midwives are expected to follow the protocol‐driven culture and orders issued by senior staff. Simultaneously, midwives are expected to follow social policy documents and the Midwives Rules and Standards that advocate choice provision for childbearing women. Quality assurors and auditors of clinical practice need to be aware that these two directives sometimes clash. Allegiance to a hierarchical system driven by protocols and orders from the top down, at the same time as providing “woman‐centred” care is often unattainable. In order for a midwife to action the woman's choice, resourceful thinking may be required. This paper aims to examine this issue.Design/ methodology/approachA descriptive interview study set out to discover strategies which midwives use to resolve conflict produced from competing directives. An appraisal of 20 midwives' views were gained from semi‐structured interviews conducted in seven maternity units in the UK. Taking a post‐positivist approach, inductive thematic analysis was used to interpret the data.FindingsThree main categories represented resourceful ways of pleasing both authority and the childbearing woman. Midwives occasionally: are economical with the truth; circumvent face‐to‐face confrontation with senior staff; and persuade women to refuse what they perceive are unnecessary and invasive interventions.Originality/valueThis paper offers unique insights into methods that midwives use to resolve conflicts in direction issued by management. It is important that auditors are aware that midwives sometimes struggle to support the preferences of healthy childbearing women. This reduces job satisfaction, delivery of care and consequently requires address.

This paper outlines a large-scale audit for the enhancement of quality of care and staff and patient safety using passive RFID (Radio Frequency ID) wrist bands, which link to a patient's database, in order to reduce errors in patient care. It has been developed with a collaboration between the University Hospital, Birmingham, UK and Napier University, UK. The key feature of the work is the usage of passive RFID tags as an integral part of a low budget out-of-the box strategic patient information system which should be compatible with most hospital IT systems.

Background Qualitative methods are increasingly used to study the process of clinical trials and patients understanding of the rationale for trials, randomisation and reasons for taking part or refusing. Patients' understandings are inevitably influenced by the recruiting clinician's understanding of the trial, yet relatively little qualitative work has explored clinicians' perceptions and understandings of trials. This study interviewed surgeons shortly after the multi-centre, pragmatic RCT in which they had participated had been completed. Methods We used in-depth interviews with surgeons who participated in the Spine Stabilisation Trial (a pragmatic RCT) to explore their understanding of the trial purpose and how this understanding had influenced their recruitment procedures and interpretation of the results. A purposive sample of eleven participating surgeons was chosen from 8 of the 15 UK trial centres. Results Although the surgeons thought that the trial was addressing an important question there was little agreement about what this question was: although it was a trial of 'equivalent' treatments, some thought that it was a trial of surgery, others a trial of rehabilitation and others that it was exploring what to do with patients in whom all other treatment options had been unsuccessful. The surgeons we interviewed were not aware of the rationale for the pragmatic inclusion criteria and nearly all were completely baffled about the meaning of 'equipoise'. Misunderstandings about the entry criteria were an important source of confusion about the results and led to reluctance to apply the results to their own practice. Conclusion The study suggests several lessons for the conduct of future multi-centre trials. Recruiting surgeons (and other clinicians) may not be familiar with the rationale for pragmatic designs and may need to be regularly reminded about the purpose during the study. Reassurance may be necessary that a pragmatic design is not considered a design fault. We conclude that it does matter if clinicians do not understand the rationale for the trial if, as we have shown here, their perception of the trial aims and methods adversely affects who they recruit; if their views affect what the patients are told; and if they mistakenly view the results as unscientific, unreliable and ultimately irrelevant to their practice.

Objectives To assess the clinical effectiveness of surgical stabilisation (spinal fusion) compared with intensive rehabilitation for patients with chronic low back pain. Design Multicentre randomised controlled trial. Setting 15 secondary care orthopaedic and rehabilitation centres across the United Kingdom. Participants 349 participants aged 18-55 with chronic low back pain of at least one year's duration who were considered candidates for spinal fusion. Intervention Lumbar spine fusion or an intensive rehabilitation programme based on principles of cognitive behaviour therapy. Main outcome measure The primary outcomes were the Oswestry disability index and the shuttle walking test measured at baseline and two years after randomisation. The SF-36 instrument was used as a secondary outcome measure. Results 176 participants were assigned to surgery and 173 to rehabilitation. 284 (81%) provided follow-up data at 24 months. The mean Oswestry disability index changed favourably from 46.5 (SD 14.6) to 34.0 (SD 21.1) in the surgery group and from 44.8 (SD14.8) to 36.1 (SD 20.6) in the rehabilitation group. The estimated mean difference between the groups was –4.1 (95% confidence interval –8.1 to –0.1, P = 0.045) in favour of surgery. No significant differences between the treatment groups were observed in the shuttle walking test or any of the other outcome measures. Conclusions Both groups reported reductions in disability during two years of follow-up, possibly unrelated to the interventions. The statistical difference between treatment groups in one of the two primary outcome measures was marginal and only just reached the predefined minimal clinical difference, and the potential risk and additional cost of surgery also need to be considered. No clear evidence emerged that primary spinal fusion surgery was any more beneficial than intensive rehabilitation.

Objective: To evaluate a progressive fitness programme for patients with chronic low back pain. Design: Single blind randomised controlled trial. Assessments were carried out before and after treatment by an observer blinded to the study and included a battery of validated measures. All patients were followed up by postal questionnaire six months after treatment. Setting: Physiotherapy department of orthopaedic hospital. Subjects: 81 patients with chronic low back pain referred from orthopaedic consultants for physiotherapy. The patients were randomly allocated to a fitness programme or control group. Intervention: Both groups were taught specific exercises to carry out at home and referred to a back-school for education in back care. Patients allocated to the fitness class attended eight exercise classes over four weeks in addition to the home programme and backschool. Results: Significant differences between the groups were shown in the changes before and after treatment in scores on the Oswestry low back pain disability index (P Conclusion: There is a role for supervised fitness programmes in the management of moderately disabled patients with chronic low back pain. Further clinical trials, however, need to be established in other centres to confirm these findings. Key messages Key messages Recent research suggests a need for a more dynamic approach with a move away from long term rest towards progressive activity and exercise This study shows that a supervised fitness programme can help to reduce pain and disability and improve patients9 confidence Beneficial effects of treatment were maintained six months after treat- ment when compared with a control group who were advised to exercise independently Simply advising patients with low back pain to exercise is not effective in reducing disability and pain

Striking differences exist in outcomes for cancer between developed countries with comparable healthcare systems. We compare the healthcare systems of 3 countries (Denmark, Norway, Sweden), 3 UK jurisdictions (England, Wales and Northern Ireland), 3 Canadian provinces (British Columbia, Manitoba, Ontario) and 2 Australian states (New South Wales, Victoria) using a framework which assesses the possible contribution of primary care systems to a range of health outcomes, drawing on key characteristics influencing population health. For many of the characteristics we investigated there are no significant differences between those countries with poorer cancer outcomes (England and Denmark) and the rest. In particular, regulation, financing, the existence of patient lists, the GP gatekeeping role, direct access to secondary care, the degree of comprehensiveness of primary care services, the level of cost sharing and the type of primary care providers within healthcare systems were not specifically and consistently associated with differences between countries. Factors that could have an influence on patient and professional behaviour, and consequently contribute to delays in cancer diagnosis and poorer cancer outcomes in some countries, include centralisation of services, free movement of patients between primary care providers, access to secondary care, and the existence of patient list systems. It was not possible to establish a causal correlation between healthcare system characteristics and cancer outcomes. Further studies should explore in greater depth the associations between single health system factors and cancer outcomes, recognising that in complex systems where context is all-important, it will be difficult to establish causal relationships. Better understanding of the interaction between healthcare system variables and patient and professional behaviour may generate new hypotheses for further research., Highlights • We examined cancer outcomes in six developed countries with comparable healthcare systems. • Clear differences exist in cancer outcomes between countries with comparable healthcare systems. • Centralisation, movement of patients between providers, access to secondary care, and list systems appear influential. • Better understanding of interactions between system variables and patient and professional behaviour may improve outcomes.

Background: Fifty percent of medications are not taken as prescribed. This is a major public health issue yet there is very limited evidence on the factors associated with medicines adherence in people with mild to moderate Intellectually Disabilities and diabetes (IDD). This study evaluated the frequency of, and factors associated with, medicines non-adherence in this group compared to people without ID but with diabetes (non-IDD).Methods: A systematic review of the literature informed the theoretical model tested. A two-stage, sequential mixed methods study with 111 people with type 1 and 2 diabetes, (IDD = 33, non-IDD = 78) was then carried out. Stage one (quantitative) compared frequency of medication adherence in the group overall, IDD and non-IDD. Univariate and multiple regression analysis evaluated associations between factors (ID, depression, side effects, self-efficacy and perceived level of social support) and medicines non-adherence. Stage two (qualitative) explored findings of stage one with 12 stage one participants’ carers using semi-structured interviews.Results: Data were collected between July 2014 and May 2016. The frequency of medicines adherence was similar in the IDD and non-IDD population (70% vs 62%, p = 0.41). The theoretical model did not predict medicines non-adherence. After controlling for support with medicines and complexity of regime (number of medications and use of insulin), depression was an independent predictor in the non-IDD and group overall (p < 0.001). In the IDD group, perceived side effects was an important, but non-significant, predictor of non-adherence (p = 0.06). Carers’ perceptions of adherence and depression were consistent with stage one findings.Conclusions: Optimising adherence to diabetes medicines is equally challenging in IDD and non-IDD populations. Associations between independent factors and adherence differed between the two groups: in the non-IDD population, depressive symptoms were associated with non-adherence whereas in the IDD population perceived level of side effects appeared most dominant. Due to small sample sizes findings were inconclusive therefore, a sufficiently powered study further investigating the relationship between adherence and side effects in people with ID and diabetes is recommended.

The heart is a fundamental aspect of the human body. Significant work has been undertaken to better understand the characteristics and mechanisms of this organ in past research. Greater understanding of the heart not only provides advances in medicine but also enables practitioners to better assess the health risk of patients. This thesis approaches the study of the heart from a health informatics perspective. The questions posed in this thesis is whether research is capable of describing and modelling heart data from a statistical perspective, along with exploring techniques to improve the accuracy of clinical risk assessment algorithms that rely on this data.The contributions of this thesis may be grouped into two main areas: statistical analysis, modelling and simulation of heart data; and improved risk assessment accuracy of the Early Warning Score (EWS) algorithm using a quartile-based technique. Statistical analysis of heart data, namely RR intervals, contributes to more informed understanding of the underlying characteristics of the heart and is achieved using null-hypothesis testing through the Anderson-Darling (AD) test statistic. The modelling process of heart data demonstrates methodologies for simulation of this data type, namely individual distribution modelling and normal mixture modelling, and contributes to assessing techniques that are most capable of modelling this type of data.For improved accuracy on the EWS algorithms, a quartiles technique, inspired by anomaly-based intrusion detection systems, is presented which enables customisation of risk score thresholds for each patient defined during a training phase. Simulated heart data is used to evaluate the standard EWS algorithm against the quartile-based approach. The defined metric of accuracy ratio provides quantitative evidence on the accuracy of the standard EWS algorithm in comparison with the proposed quartile based technique.Statistical analysis in this thesis demonstrates that samples of heart data can be described using normal, Weibull, logistic and gamma distribution within the scope of two minute data samples. When there is strong evidence to suggest that RR intervals analysed fits a particular distribution, individual modelling technique is the ideal candidate whilst normal mixture modelling is better suited for long-term modelling, i.e. greater than two minutes of heart data. In comparative evaluation of the standard EWS algorithm and the quartile-based technique using modelled heart data, greater accuracy is demonstrated in the quartiles-based technique for patients whose heart rate is healthy, but outside the normal ranges of the general population.

Microspheres have become an important material in the biomedical and environmental sciences, particularly for use in the detection of pathogenic microorganisms and toxins as well as for use as carriers in drug delivery. In this study, their use in microbial detection, with particular emphasis on immunochromatographic assays, was investigated. Two main types of microspheres were studied: colloidal gold and polymeric. The original plan to combine the use of colloidal gold and fluorescentdye-labelled PMMA microspheres as a signal generator, in order to enhance detection signals and improve detection limit, was abandoned when preliminary detection experiments showed that the use of colloidal gold was not so beneficial after all, taking into account the amount of light lost to absorption by the gold particles. Therefore, it was decided to use Rhodamine B-labelled PMMA microspheres. PMMA particles, both unlabelled and internally labelled with Rhodamine B, were synthesised by emulsion polymerisation and yielded monodisperse particles of around 200 nm and 300 nm, respectively. An attempt to co-polymerise MMA with HEMA to form 200 nm-sized monodisperse P(MMA-HEMA) microspheres in order to create functional –OH groups on the microsphere surface to be used in chemical covalent coupling with monoclonal antibodies resulted in aggregated microspheres and non-uniform particles, and were therefore not used for covalent coupling. Attachment of monoclonal antibodies onto the surface of Rhodamine-B labelled PMMA microspheres by passive adsorption also resulted in aggregated particles. Diffusion and detection experiments were carried out on the Rhodamine-B labelled PMMA microspheres. Diffusion of PMMA microspheres along a nitrocellulose strip was found to be 42% slower than the diffusion of colloidal gold along a nitrocellulose strip. Using a spectrophotometer, detection experiments were performed on dilutions of an original stock solution of 1% w/v PMMA in distilled water. The detection limit was found to be of the order of 10-3. This study has investigated the materials that constitute an immunochromatographic assay and has illustrated some of the complications associated with the synthesis of copolymer microspheres and immobilisation of antibodies onto their surfaces. Further work on how to improve on the methods discussed in this study have also been recommended.