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The prevailing rates of morbidity and mortality resulting from accidents in the youngest and most vulnerable members of our population are a cause for concern. Reducing childhood accidents has been identified as a priority for improving health in the United Kingdom and in many other countries. Despite mothers being identified as the main carers for pre-school children, relatively little research has examined mothers' perceptions of childhood accidents or explored their experiences and expectations of health professionals in promoting safety. This study examines mothers' perceptions of childhood injury risk, the ways in which mothers develop knowledge and skills for keeping their children safe and how they are motivated to adopt accident prevention strategies. The mothers' perceptions of the health visitor role in promoting the safety of pre-school children are also examined. The study was undertaken within on Health Board district in Scotland, using a combination of quantitative and qualitative survey methods. A questionnaire was posted to eight hundred mothers of pre-school children, randomly selected from Primary Health Care Data Base and to two hundred mothers whose pre-school children had attended the Accident and Emergency Department as a result of an accident within three months prior to the survey. From the survey respondents, forty members were selected as key informants and participated in qualitative, in-depth interviews. Quantitative data were analysed using the Statistical Package for Social Scientists. The interviews were tape recorded and transcribed to facilitate a systematic approach to content analysis. The combined results reveal the opportunity of caring for children safely, although certain aspects of this process can be understood by recognising distinct but interacting knowledge, perceptions and motivations. Mothers believed that much of their knowledge for protecting their children was common sense, indicating how many safety practices were socially constructed according to the norms of their social network. Mother's perceptions of childhood injury risk were influenced by their families' accident experiences. However, new or unfamiliar risks were often not anticipated by mothers. This lack of generalisation from accident experiences and from prior knowledge may limit maternal motivation to adopt specific safety practices.

Background: Infectious disease has become an increasing field of interest due to the recent COVID-19 pandemic on a long-standing background of nosocomial infections, which have contributed to excess and largely avoidable morbidity and mortality, worldwide. In the hospital setting, the appropriate use of personal protective equipment is the mainstay of preventing the transmission or acquisition of nosocomial pathogens and yet, adherence among health professionals has been less than desirable. Suboptimal adherence to personal protective equipment remains a key issue within Saudi Arabia but there has been little understanding of the factors contributing to this problem. Therefore, this research addressed this gap through conducting a mixed-methods study that evaluated factors associated with nurses PPE use. Methods: A mixed-methods study design was used to develop and field a closed-ended survey is strongly influenced by the Integrated Behavioural Model (IBM). The (IBM) was used to elicit the psychological, behavioural, and contextual factors (e.g., attitudes, subjective norms, and perceived control) influencing nurses' adherence to PPE guidelines. In keeping with the IBM, research was conducted in a phased approach: a convenience sample of nurses was obtained from two hospitals in the North of Saudi Arabia: 14 completed open-ended interviews (phase 1, qualitative elicitation phase) and in phase 2 (quantitative behavioural prediction phase), 279 nurses completed a self-report survey informed by the phase 1 data, using random sampling: the response rate was 96.5%. Data were gathered from August 2020 to April 2021. Results: Based on the themes identified through the qualitative content analysis, survey items were constructed for each construct (e.g., attitudes) using a 7-point bipolar scale. The final instrument demonstrated high internal consistency (Cronbach alpha of 0.92) and desirable test-retest reliability (intraclass coefficients mostly exceeding 0.80). For the direct measures of the independent variables, the mean scores for attitudes, subjective norms and perceived behavioural control were 5.7, 5.5 and 3.5, respectively, on the 7-point scale, indicating that nurses tended to hold positive attitudes, receive positive influence from others and perceptions of others' judgements upon their intentions to adhere to PPE precautions. For the indirect measures, the mean scores for behavioural beliefs and outcome evaluation, control beliefs and power and normative beliefs were 6.0, 5.1 and 4.4, respectively. These findings also indicate that most nurses held favourable intentions to comply with PPE due to understanding of its importance in protecting patient safety but encounter numerous obstacles in adhering to PPE guidelines all the time. Multiple regression analyses showed that the overall model accounted for 62% of the variance in nurses' intentions to comply with guidelines (R² = 0.62, p=0.000). Notably, the attitudes construct was the strongest predictor of nurses' intentions to comply with guidelines (R² = 0.58, p < 0.001), followed by subjective norms (R² = 0.32, p < 0.001), and perceived control (R² = 0.15, p < 0.001). Overall, nursing adherence during the COVID-19 pandemic received influence from a broad range of factors; some acting as barriers to PPE adherence, whilst others encouraged said adherence. Nurses' attitudes imparted the strongest influence over PPE adherence, taking precedence over the more practical and hierarchical influences of PPE access and usage. Implications: This study provided the first insight into the varied factors influencing adherence to PPE among Saudi Arabian nurses. Key recommendations for ongoing practice include a need for ongoing and regular education and training to maintain nurses' positive attitudes towards PPE adherence, recruiting and deploying infectious disease nurses to act as role models in infection prevention and control, introducing measures to mitigate nursing anxiety and fear of using equipment and establishing a means to evaluating infection rates. Overall, it is intended that this work will lead to meaningful improvements in nursing adherence to personal protective equipment and in turn, reduce adverse patient outcomes related to nosocomial infections.

Background: The Long Term Care (LTC) policy in Taiwan was developed in response to Taiwan's ageing society and is aimed at addressing the increasing demand for healthcare services (Ministry of Health and Welfare, 2018). Stroke is often seen as an age-related disease. Medical advances have enabled an increase in the number of stroke survivors, and have consequently increased the population living in communities with long-term health conditions or residual complications post-stroke (Hsiao, 2010; Donkor, 2018). In Taiwanese society, adult children generally take care of their ageing parents. This generational relation bond in families stems from filial piety and a familial belief system that forms the backbone of the family caregiving system. Demographic changes in combination with more women joining the paid workforce have impacted negatively on the previously readily available but unpaid care work within the family, thus raising the demand and need for the provision of LTC services. The Taiwanese community comprises different ethnic groups, and insufficient attention has been paid to the specific healthcare needs of people from different backgrounds. This ethnography explores how stroke survivors and their family caregivers utilised LTC services from the perspectives of indigenous and non-indigenous participants. Methodology and methods: A focused ethnographic approach was employed for this study. Data collection included non-participant observation of LTC service delivery and involved semi-structured interviews with 12 dyads of stroke survivors and their family caregivers. The research participants were from indigenous, urban-based indigenous and non-indigenous communities. Each ethnic group consisted of four dyads. Following transcription, the data were transferred to NVivo 12 for analysis. The data analysis reflected an inductive-abductive approach, drawing on Bury's (1982) biographical disruption, Glaser and Strauss' (2011) status passage theory, and in its later stages, Giddens' (1984) structuration theory. Findings: The findings show that post-stroke life was underpinned by the family caregiving system and LTC system in Taiwanese communities. Each dyad's needs and expectations for their post-stroke lives informed their post-stroke recovery trajectory. The extent to which LTC coordinated the individual needs within the situated contexts of both the family and community shaped the nature and quality of recovery and this reflected the individual's recovery trajectory. However, the coordination of care resources faced obstacles that resulted from social determinants. The predominant socioenvironments were the key factors that inhibited healthcare access. Urbanisation was a fundamental reason for the urbanised indigenous participants' slower movement along the recovery trajectory. They seemed to be invisible in the LTC system, and their healthcare was not as well supported. They had lost their ethnic connection to the native tribes and administrative identity in the LTC system concurrently, as they detached physically from the tribal communities and sociopsychologically from the urban communities. The geographical barrier was an unconquerable distance preventing healthcare access for the indigenous people located in mountainous areas, as the need for transportation increased and impeded the accessibility of healthcare facilities. The LTC workforce served as an agency in overcoming some of these barriers and optimising the system organisation. The agency of the LTC workforce functioned in different patterns. In the non-indigenous context, the LTC workforce assumed a supplementary role of collaborating with other available resources in the community. Their agency was expected to be more skilful and independently applied in the mountainous indigenous context. In the urban-based context, this agency was enacted through information and resource linking. Conclusions: The conceptual model illustrated how structuration theory (Giddens, 1984), biographical disruption (Bury, 1982) and status passage theory (Glaser and Strauss, 2011) could help to interpret the world of people recovering from a stroke and engaging with the LTC system in society. It identified socio-environments as the key barriers and the workforce agency as the facilitator for LTC implementation. Therefore, LTC policy should not aim to achieve equal healthcare access; instead, it needs to draw support from flexible, adapted strategies in order to address healthcare equity for individuals.

Background: Research utilization in nursing practice has shown to improve quality of care (Dufault and Sullivan 2000; Rutledge and Bookbinder 2002), however, the extent to which nurses use research in practice remains questionable (Squires et al 2011). It is known that leadership is crucial in nurses' research utilization (Newhouse 2007; Gifford et al 2011; Reichenpfader et al 2015) yet the dimensions of this vital leadership are largely unknown. Consequently, in this grounded theory study, I aimed to develop a middle range theory on the role of leadership in nurses' research utilization. Design: I used a constructivist grounded theory (Charmaz 2014) methodology with Clarke's (2005) situational analysis as an analytical tool within a constructivist framework. Beginning with purposive sampling and later progressing to theoretical sampling, I conducted 20 semi-structured interviews of healthcare professionals in various roles within one health board in Scotland from September 2017 to August 2018. Interviews were audio-recorded, transcribed, and NVIVO was used to manage data during the analysis. Findings: The findings of this study illuminate the links between leadership in the form of empowering constructs and nurses' professional identity to achieve research utilization. The resulting theoretical model show three main categories - integrating research into the nursing role; building relationships; and shifting culture - that leadership can empower nurses structurally as well as psychologically in affecting the understanding of their own professional identity. Additionally, the theoretical model was informed by two other processes from using situational analysis in this study: a social world/arenas map of nurses' research utilization and a positional map indicating the various stances within my data on nurses' empowerment and subsequent research utilization. In this thesis, I have found support for recent contentions in the leadership literature of leadership as empowering others rather than focused on power-based individuals (Dambe and Moorad 2008; Kellerman 2013; Northouse 2016). Furthermore, I have opened new avenues for research in relating research utilization with professional identity, an assertion which is currently missing from the body of literature. This provides valuable guidance for nursing leaders at all levels of healthcare in understanding the role of professional identity in research utilization and the use of empowerment in affecting change. My use of situational analysis with constructivist grounded theory is also a novel research method and only done previously in three other studies (Mills et al 2007; den Outer et al 2012; Khaw 2012), although none have incorporated the use of positional maps.

Background Since the concept of end of life care was first introduced in the late 80's in Hong Kong (Chan, 2002) and Taiwan (Glass et al, 2010), research interests examining the influence of Chinese culture in respect of death, dying and end of life issues has gained popularity (Bowman & Singer, 2001; Chan & Chow, 2006; Chen et al, 2014; Hsu et al, 2009; Mjelde- Mossey & Chan, 2007; Tung, 2011; Zhou, 2016). However, there is a dearth of empirical examination on the process of the establishment and development of the concept and service of end of life care, within a socio-cultural Chinese environment. In the context of Macao, there is only one study (Lo, 2002) describing the establishment of the inpatient hospice, and to date, there is no empirical evidence on the establishment of end of life care, nor on factors that influence the development of end of life care in the context of Macao. Aim The aim of this case study was to develop a theoretical understanding of how the end of life care was introduced, established and developed, and to examine the factors that had shaped the end of life care in Macao. Methods A qualitative case study research approach (Stake, 1995) was conducted and the end of life care in Macao was the case of this research. Data was collected through in-depth, semi-structured interviews with the initiators (n=3) and developers (n=8), from three different settings that provide and promote end of life care in Macao. Interviews were digitally recorded and transcribed. Qualitative data analysis software, Nvivo 11, was used to organise the data and facilitate analysis. All data was analysed based on the principle of thematic analysis (Braun & Clarke, 2006). Findings Through thematic analysis, the emergence of end of life care in Macao can be understood to some extent to have developed through a social movement formation. Initiators with diverse backgrounds collectively conceptualised that the suffering of people as experienced at the end of their lives in Macao was a social problem needed to be changed, and they subsequently developed different approaches in pursuing for change. This findings also revealed that the growth of end of life care has become stagnant after the initial wave of establishment. The framing perspective (Snow & Benford, 1988; Snow et al, 2014; Snow et al, 1986) was adopted in this research in aiding the conceptualisation of end of life care in Macao as a social movement, and the development of a theoretical understanding regarding the development of end of life care in Macao. This research identified three key conceptual perspectives elucidating the developmental trajectory and factors contributing to the growth and then stagnation of end of life care in Macao. These three conceptual perspectives were: - The conceptualisation of the problem with dying: the suffering of people as experienced at the end of their lives (the grievance in the context of the framing perspective) - The incoherent strategies developed by initiators in establishing end of life care (the lack of internal frame cohesion) - The variety of contextual and conceptual constraints that influenced the subsequent development and then stagnation of end of life care (the lack of external frame cohesion) within the context of Macao The findings indicate the integration of these three conceptual perspectives has led to a holistic, theoretical understanding of the development of end of life care in Macao addressing the research aim and contributes to knowledge about end of life care. With specific regard to the socio-cultural environment of Macao, the study has taken a unique theoretical approach in developing understanding of the end of life care as a social movement by way of the framing perspective. This thesis has proposed a new way to examine the emergence of end of life care, which would facilitate the exploration of end of life care development in other cultural contexts.

Background: The rights of children to freedom of expression and receiving information are underpinned by Articles 12 and 13 of the United Nations Convention on the Rights of the Child (UNCRC) (1989), which was ratified by the Malaysian government in 1995. There has been increasing shifts toward recognising the importance of children’s rights with many initiatives to realise and uphold the rights of children in Malaysia. However, no previous studies of children’s participation have been conducted in Malaysia. The aim of this study was to explore children’s participation in decisions regarding their nursing care from the perspective of the children, their parents, and nurses in an oncological ward in Malaysia. Methods: This was a focused ethnographic study. Participant observation was carried out with 61 participants (21 children, 21 parents, and 19 nurses) in the paediatric oncology-haematological ward, Malaysia. Semi-structured interviews were conducted with 21 participants (6 children, 7 parents, and 8 nurses). The existing documents pertinent to the research focus were examined to validate the participant observations and interview findings. Data were analysed using Roper and Shapira’s (2000) focused ethnographic data analysis techniques. Findings: There were different degrees of the participation of children in decisions among children diagnosed with leukaemia, including: being physically present, being informed, being consulted where children can express their wishes and opinions during the provision of nursing care, and being able to make their own decisions in relation to their nursing care. The degrees to which children participated in decisions fluctuated throughout the course of their hospitalization; moving from lesser degrees of participation (passive participant) to greater involvement (active participant) and vice-versa. The extent to which children participated in decisions were significantly influenced by the children’s preferences for participation. The preferences of children also fluctuated over the course of their illness and treatment. There were several factors contributing to children’s participation in decisions including; i) interpersonal relations in the child-parent-nurse interactions; ii) experiences of the child (veteran or novice); iii) attitude of nurses; iv) parental role; and v) the ward policy. Conclusion: The children want to be involved and really appreciate participation in communication and decisions but their opportunities for participation are somewhat limited. This study calls for a flexible model to assess children’s preferences for participation and different forms of participation for children in relation to decision-making in paediatric oncology.

Background: The safety of critically ill patients during inter-hospital transfer is recognised as a globally important issue. However, little evidence exists pertaining to the care provided by transfer nurses throughout the processes of inter-hospital transfer in rural community hospitals where there is a high risk of adverse clinical events occurring during transportation. Aim: The overall aim of the study was to explore transfer nurses' understanding of the delivery of quality of care during the transfer of critically ill patients from rural community hospitals to a tertiary regional hospital in Thailand. Design and Methods: The theory of symbolic interactionism (Blumer, 1986) and focused ethnography methodology were used. Data were collected using multiple qualitative methods including sixteen semi-structured interviews with transfer nurses, fourteen observations of critically ill patients' transfers from three rural community hospitals to a tertiary centre and twenty-three subsequent handover events and the analysis of transfer documents from four hospital settings (e.g. one regional hospital and three rural community hospitals) in Thailand. Translation from Thai into English and back translation into vernacular language was required. Inductive, thematic analysis was conducted to identify major themes by using qualitative data analysis software, NVivo 10 to assist data management during the analysis. Results: Five major themes emerged including (i) protective factors influencing safe transfer care, (ii) barrier factors influencing safe transfer care, (iii) behavioural patterns in transfer care processes, (iv) maintaining the health condition of the patients, and (v) overcoming adverse events. These particular themes elaborate the meaning of the quality and patient safety of transfer care, the provision of care for safe transfer care, and significant contextual factors that influence the quality of inter-hospital transfer care for critically ill patients. In addition, Donabedian's model (Donabedian, 1966, 1988) incorporated within the concept of context and culture was utilised to assist in conceptualising the framework for the quality of inter-hospital transfer care of critically ill patients in Thailand. Conclusion: The Donabedian model is useful as it is simple, but it does not include detail of the organisational context and culture as determinants of care quality. A conceptual framework for the quality of inter-hospital transfer care of critically ill patients in Thailand was therefore proposed. This study has expanded on current theoretical knowledge of the quality of inter-hospital transfer care by elaborating the patterns of thought and the behaviour of transfer nurses during provision of care throughout the processes of the inter-hospital transfer. It also highlights the limitations of organisational structure and the environment in which transfer work takes place, including issues on handover processes in hospital transfer care. The results can be useful to transfer nurses in that they facilitate greater understanding of the provision of better quality of care. They also help to inform hospital policy makers how to ensure safety of critically ill patients being transferred from community hospital settings.

Background: Concerns have been well documented about women either dying or developing severe morbidities from prolonged and obstructed labour. These concerns have noted that maternity care during labour has not been of a sufficient standard to improve the outcome for women giving birth in Malawi. This ‘failure to save’ women remains, despite assertions that obstructed and prolonged labour can be prevented through appropriate decision making during the progress and management of labour. Midwives in Malawi form the majority of maternity healthcare workers and an important aspect of their decision-making role is to assess the progress of labour when caring for women in labour. To date, there has been limited exploration of either midwifery decision making during labour or the contextual factors that influence midwives’ decision making. The aim of this study was to explore how Malawian midwives make decisions during the first stage of labour in a hospital setting and to identify the contextual factors that influence their decision making. Design and Method: Using a qualitative ethnographic research approach, 27 participant observations, 26 follow-up interviews and document reviews comprised the data collection. Nine Malawian nurse-midwives who worked at a tertiary (n=5) and a secondary referral hospital (n=4), with a mixture of qualifications and experiences, participated. Each nurse midwife was observed three times with subsequent follow-up interviews. Interviews were conducted in a vernacular language, audio-taped, transcribed, translated into English and back translated into vernacular language. Qualitative data analysis software, NVivo 10, was used to assist with data management for the analysis. All data was analysed using the principle of theme and category formation. Findings: Three major themes were identified - contextual factors influencing midwifery decision making - the role of cue acquisition - the role of the partograph during care of women in the first stage of labour. Integration of the themes has led to the development of a proposed conceptual model of ‘supporting normality’ during the first stage of labour, which suggests that the midwives strived to make decisions during the care of women in labour with the aim of supporting the normal physiological processes of labour. The first theme illustrates that for Malawian midwives, decision making is a complex and contextually dependent undertaking. In everyday practice, decision making was influenced by multiple and competing factors but the midwives developed strategies to manage and control the context of their practice and facilitate decision making. The role of cue acquisition comprised a six-stage subprocess illustrating the ways in which midwives utilise assessment data to reason and make decisions during the care of women in labour. These processes involved the midwives building a case for each woman’s labour progression by piecing together segments of information they obtained. This process was striking when there was uncertainty in a woman’s progress of labour as they used deductive thinking by cross-checking data obtained across the labour progression span. There was a constant forward and backward moving of thought processes supported by actions that uncovered real case-building evidence for informing decisions about whether to intervene or not. The model further indicates the role of the partograph, which alerted midwives to the presence of progress or non-progress of labour. Although the partograph acted as an adjunct to the midwives’ decision making that could indicate opportunities for early intervention in labour if labour appeared not to be progressing, the midwives were sometimes cautious about its interpretation. This thesis has expanded on current theoretical knowledge of decision making by elaborating on the processes midwives employ to make decisions as they care for women in labour. It also illuminates the impact of contextual factors on decision making, and elucidates various strategies midwives use to advance their professional role. The emerging conceptual model provides implications for future midwifery practice, education and policy both in Malawi and worldwide.

Background: The professional development of midwifery in China has been challenged by its marginalised professional status and the medical dominance within midwifery practice in the contemporary maternity care system. There has been growing confusion about, ‘Who the midwife is and what does the midwife do?’ within and outside the profession. The sense of identity crisis for the profession has become particularly salient when Chinese midwifery becomes a sub-branch of the nursing profession during the contemporary period. If, however, we consider the International Confederation of Midwives (ICM) Mission Statement (2008: 32) that midwives are the ‘most appropriate professionals for childbearing women in keeping childbirth normal’, then the focus on a greater understanding of midwives is needed. It is the aim of this research to facilitate this understanding by exploring how hospital-based Chinese midwives construct their professional identity in the contemporary maternity care system and the factors that significantly influence the process. Design and Method: A Constructivist Grounded Theory (CGT) study was conducted to achieve the research aim. A sample of 15 midwives and 5 women participants was recruited between October 2010 and May 2011 from a capital city in one province of China. The accounts from the participants in the form of in-depth individual interviews were digitally recorded and three work journals from midwife participants were also included to facilitate the exploration of the study subject. NVivo 8 was used to assist with data management for the analysis. Findings: Six principle categories were identified: ‘institutional position’; ‘organisational management’; ‘professional discourse’; ‘compromising strategies’; ‘engaging strategies’; and ‘hybrid identity’. The integration of the principle categories has developed the theoretical model ‘navigating the self in maternity care’, which suggests that professional identity construction in midwives is a dynamic process, involving a constant structural and attitudinal interplay between the external (‘obstetric nurse’) and internal (‘professional midwife’) definitions of the midwife. The model indicates that the midwives’ professional identity construction was contextualised in their ‘institutional position’ in the contemporary maternity care system. In everyday practice, midwives experienced identity dissonance in relation to two competing identities: the ‘obstetric nurse’, bound up to the ‘organisational management’ in hospital settings; and the ‘professional midwife’, associated with the ‘professional discourse’ in the midwifery profession. Two types of strategies were identified to reduce the identity dissonance – ‘compromising strategies’ and ‘engaging strategies’ – which resulted in a ‘hybrid identity’, as the construction of professional identity in individual midwives is navigating along an identity continuum with ‘obstetric nurse’ and ‘professional midwife’ at opposing ends. This thesis has expanded on the current theoretical knowledge of identity work by elaborating on the discursive practices professionals employ to legitimate their professional identity and the various strategies individuals use to negotiate their identities at work. It has also extended attention to the influence of institutional forces on professional identity construction. With specific regard to Chinese midwifery, this emerging theoretical model provides a number of possible implications for midwifery practice, education and policy which would facilitate the exploration of effective operational processes for midwives in China to develop professionally.

Background: Nursing shortage is a worldwide phenomenon; in rural areas, this shortage is exacerbated by geographical imbalances. Reducing the inequality of health outcomes between rural and urban areas requires improvement in the rural nursing workforce. Thus far, little research has been conducted on the recruitment of nursing students to rural nursing in China. Aim: This study aimed to explore nursing students’ perspectives of rural nursing practice and their intentions to work rurally after graduation, and to identify factors contributing to those intentions. Methods: Exploratory interviews were conducted with eleven nursing students to obtain their perspectives of rural nursing practice. This was followed by a hand distributed and collected self-completion questionnaire survey that involved 445 final year nursing students in six nursing schools in one province in China. The questionnaire measured students’ rural career intentions and their perceptions of rural nursing practice. The survey data were collected between December 2011 and March 2012. The response rate for the questionnaire survey was 89%. Results: The results indicated that the majority of final year nursing students did not intend to work rurally. The most frequently cited barriers deterring them from considering a rural job were the perceived fewer opportunities for skills development and learning, potentially lower financial rewards, and family members’ disapproval of rural working. Regression analysis showed that the length of time living rurally and educational level were the most important predictors of nursing students’ intentions to take a rural job immediately following graduation. The logistic regression illustrated that rural identification, degree, and rural placement experiences were significant predictors for nursing students’ intentions to work rurally in their future nursing career. Conclusion: Nursing students with high intentions to work rurally were rare in China. Rural background had a positive impact on students’ intentions to work rurally. Students with a degree were less likely to work rurally.

The aim of this study was to investigate the principles and factors underlying the culturally competent nursing care of asylum applicants. Asylum applicants are a highly vulnerable group, whose health is often severely compromised prior to arrival in the UK due to exposure to torture, violence and rape. Although they are entitled to primary health care services whilst their asylum claim is under consideration, their level of welfare support has been significantly eroded over the last decade. An analysis of the nursing literature revealed mainly US notions of cultural competence, which were based on a private health care insurance system rather than a universal health care system of equitable, accessible and non-discriminatory service provision, such as the NHS. A Five Steps Model of cultural competence (Quickfall 2004) was later revised to provide a theoretical framework for this research study. Data for this ethnographic study were collected during 2005-2007 with asylum applicants and community nurses within one Health Board in Scotland, using participant observation, individual, narrative and group interview methods. The data were analysed for their categorical content. The findings are presented as vignettes to highlight cultural competence issues. Three major themes emerge from the study findings, which highlight the intermediary function of community nursing. The provision of equitable, accessible and non-discriminatory services remains pertinent in the 21st century. Secondly, the cross-cultural promotion of health involves a partnership process to ensure effective communication and the negotiation of person centred care. Thirdly, the delivery of socially inclusive services requires the aiding of asylum applicant adaptation to a new host environment. This study contributes to community nursing knowledge in explaining, through synthesis of the literature and study data, a model of cultural competence for the care of asylum applicants. It also provides a set of best practice statements, which require further investigation.