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This thesis presents a grounded theory study of UK health visitors practising in an increasingly integrated, collaborative, service user focused healthcare system. Emphasis is placed in policy on a preventative, public health approach to addressing the ongoing health needs of the population. This has provoked a national debate on the healthcare contribution of health visitors. Better use of health visiting capacity and closer alignment of the role with the collaborative public health agenda have been identified as a national priority. The theoretical framework for this study has been developed from the symbolic interactionist premise, that individuals continually reinterpret their world in the context of their social interaction with others. Data has been collected from direct observation and individual interviews. The process of constant comparative analysis has generated four interrelated data categories: professional role in action; interprofessional working; local micro systems for practice and professional role identity (core category). Three models have been developed to support the discussion of the findings. The first two make explicit the inter-relationship between the concepts identified in the data and interactive processes relating to the maintenance of identity. The third model proposes a process of interprofessional role change. It links the uniprofessional and interprofessional dimensions of practice to the core principle of valuing individuals through the maintenance of equilibrium in their professional role identity. Embedding a process for feedback on identity is identified as important. This thesis theorises that role change facilitation should enable individuals to continually renegotiate their professional role identity in the context of their practice. It also suggests that promoting a sense of collective identity within a professional group will enhance the experience of individuals involved in a collaborative role change process. The thesis concludes with a consideration of its implications for health visiting and others in the healthcare system, in seeking to maintain their role identity in a turbulent practice environment.

The evolution of this research emerged from experiences in the researcher's clinical practice as a nurse practitioner in a variety of urgent care facilities, and the personal queries raised regarding the consistency of the level of practice and evidenced competency of clinical staff in emergency and unplanned care using the title "practitioner". These realities are apparent as at present in the UK no legislative requirement exists for nurse practitioners (NPs) to gain formal preparation or qualification. Guidance and direction have been seen in The Advanced Care Practice framework (HEE,2017), yet legislative protection remains absent. Such legislative protection is however seen in other healthcare systems across the world, such as Australia and the US. This research looked at the journey towards proficiency, the competency to proficiency journey, that is experienced by NPs as they qualify to become NPs, and how they move on in that journey. It incorporated the concepts of role identity, competency, capability and confidence, all of which have been researched in relative isolation. This study explored the NP's practice experiences by bringing these concepts together, focusing on emergency nurse practitioners (ENPs), and how these experiences influence or effect their feelings of role proficiency, from the perspective of the autonomous and clinically proficient ENP. The research question "how do ENPs' experiences in practice influence their feelings of role proficiency?" was addressed with the objectives to examine and understand the meaning of role proficiency to ENPs, to identify practice experiences that influence role proficiency and identify and understand how these practice experiences influence ENPs' feelings of role proficiency. A hermeneutic phenomenological methodological approach was used to interpret the lived experience of the ENPs in practice. A purposive sample of 10 ENPs was interviewed, and a three-stage interpretive process was used to gain access to the object of investigation and interpret its meaning and lived experience for the ENPs. Six themes emerged from the data extraction process: the meaning of role proficiency, relationships, confidence, learning and knowledge, exposure and experience, and care. An analytical category tool identified five key outcomes for discussion that linked the themes to the research question: being good at the job, central role of confidence, relationship issues, coping strategy and the influence of care. This study highlights the need to give attention to the experiences that lead the ENP to feelings of proficiency and their inclusion in clinical educational programmes. The importance placed on the connection of the components required for being good at the job, and how this is constructed by the ENP and should be incorporated, will be presented. Attention was also paid to the influence of confidence and the impact that relationships have upon feelings of proficiency. An increased focus was given to the development and management of relationship experiences, alongside the traditional competency-based clinical achievement frameworks. A direct approach, assessment, enablement and focused development of emotional intelligence and coping strategies was found to facilitate and maintain feelings of proficiency. Acknowledgement is made that not only is care the focus from the patient's perspective but, alongside this, that care is the central motivating factor of the ENP, driving the elements that contribute to feelings of proficiency. This underpins the emotional intelligence required to perform the role and achieve feelings that allow the ENP to remain in their zone of proficiency to deliver the care the role focuses on.

Background: The operating room (OR) environment is a unique context within the clinical setting, which brings together interprofessional healthcare providers in a confined space where patient care is directed at a concentrated focal point. The notion that a team of experts do not simply merge to form an expert team is reflected through reported failures in teamwork in the OR. Interactions between and among interprofessional healthcare providers within the OR context are critical in optimising the way in which the team works together. There is limited empirical research exploring teamwork in the OR through the perceptions of interprofessional healthcare providers who have experience of teamworking in this unique context. Aim: The aim of the research was to address the gap in knowledge and develop a more comprehensive understanding of teamwork in the OR. Specifically, the research aimed to explore interprofessional teamwork in the OR exclusively, through the perceptions of individuals who had personal experiences of working in such teams. Methodology and Methods: This research was guided by Strauss and Corbin's (1990) approach to grounded theory, influenced by the theoretical perspective of symbolic interactionism. The sample population comprised of a group of individuals in an established interprofessional role, who could contribute to understanding 'teamwork as imagined' and 'teamwork as done' within the OR. Using a theoretical sampling strategy, data were collected via 14 in-depth semi-structured interviews, three observation periods and informal interviews, with accompanying detailed field notes. Data were analysed using open, axial and selective coding techniques, supported by constant comparative analysis until theoretical saturation was achieved. Findings: The analysis generated four data categories. Antecedents of Familiarity is the core category that helps to describe the social processes of interactions of interprofessional healthcare providers during OR encounters. The three sub-categories, Shared Understanding, Positive Disposition and Professional Communication, provide further explanation of the micro, meso and macro contexts that facilitate and/or impede interactions during teamwork. To reflect participant perceptions of the complex nature of teamwork in the OR, a grounded theory was constructed and integrated into The Interprofessional Collective Effort (ICE) Model of OR teamwork and the underpinning PerfORm taxonomy. Given the importance of interactions among and between interprofessional healthcare providers in the OR, the new theoretical insight gained from this model provides a more comprehensive understanding to guide educators, leaders/managers and policymakers in planning strategies to support interprofessional teamwork in the OR. Original contributions to the existing knowledge base around OR teamworking are offered, alongside a basis from which to address emerging implications for academic disciplines, research areas, interprofessional education and collaborative team training.

Introduction: Integrating interprofessional working (IPW) as a contemporary response to the ever changing needs of the UK population is a 'gold standard' healthcare strategy (including in a stroke care setting). However, difficulties in collaboration remain despite the ubiquity and the barriers being well understood. Aim & Methodology: Effective relationships are important for IPW, yet an in-depth understanding on how relationships are perceived, formed and sustained is limited. This study aimed to address this area of limited knowledge by exclusively exploring interprofessional relationships through the individuals who work within a stroke care MDT context. A constructivist grounded theory methodology influenced by the theoretical perspectives of symbolic interactionism and social constructivism was used to address the study's aim. The constructivist methodology, investigates social behaviour by its ability to interactively link the researcher and the participants under study, while acknowledging that knowledge and reality are not fixed, but are multiple and occur in the social contexts which the participant interacts in. The sample population was selected through purposive sampling, followed by the theoretical sampling strategy. In total, 14 stroke care professionals were recruited. Thirteen of these participants were observed in practice, and out of the 13, 12 were individually interviewed, resulting in data saturation from 25 data collection episodes. Data was analysed using the constant comparative analysis process. Findings: Four interrelated categories emerged from analysis; Developing a sense of belonging, Rewards and recognition, Inclusive working and learning and Interprofessional compassion. The grounded theory model of experiencing growth through interprofessional relationships: a stroke care MDT setting was constructed to reflect the MDT stroke care participants' relationship perceptions and to support the discussion of the findings. The original model proposes a process for which IPW relationships can be understood, with three overarching theoretical perspectives providing insight into the social process, functions and motives of interprofessional relationships in stroke care. This new theoretical insight offers an original contribution to practice, education and theoretical knowledge, by providing a comprehensive and multi-dimensional interpretation, for understanding the IPW relationships that exist and the process in which they can be developed and sustained. It additionally contributed new research opportunities which includes an interprofessional application of the IOS tool.

Adult critical care is complex; therefore, the workforce develops specialist knowledge. Whilst interprofessional collaboration is concomitant with critical care, the ways different professions learn together are indistinct. This thesis explores the factors influencing interprofessional learning (IPL) culture in adult critical care, providing rich insight into staff perceptions and experiences of IPL, and investigates factors that promote or inhibit IPL in this acute care environment. IPL culture was explored using focused ethnography, adopting an interpretive epistemological position, with an ontological stance of social constructionism. Data collected over 12 months, in three adult critical care units in North East England, used partial participant observation and semi-structured interviews with critical care professions. Rich ethnographic data was thematically analysed. Findings showed that IPL occurred in all environments studied, but engagement with IPL differed across professions and potential IPL opportunities were missed. IPL culture was shaped by individuals, teams and organisations, and a changeable IPL climate existed which was affected by holistic influential factors. The environment was key to embedding IPL; in a space the visibility of professions promoted IPL more than their proximity, and each critical care department adapted spaces for IPL to occur. The IPL environment guide developed from the research findings indicates ways to enhance IPL. Whilst formal IPL opportunities were limited, professions perceived safe holistic patient centred care as a shared motivation to learn from others. Professions shared knowledge based upon their assumptions of peers' expertise, and IPL was enhanced when rationales underpinned instructions and when decision-making was interprofessional; the CAUSE decision-making model is a framework developed that incorporates rationales to promote IPL. Four stages of IPL were observed: preparing, enquiring, acting, and sharing, and IPL was enhanced when staff effectively collaborated, felt safe to ask questions, and when they humanised their professional role through humour and emotions as members of the community of critical care practice. With rich insight into the complexities of IPL in adult critical care, further work is needed to explore potential IPL improvements based upon the ethnographic findings in this thesis.

Contemporary higher education, healthcare and healthcare professional education is changing continuously. In times characterised by change and uncertainty, with increasing opportunities for networking and collaboration, educational curricula with an emphasis on 'process' rather than a more traditional, mechanistic emphasis on 'product' would seem appropriate in looking towards the future. Informed by themes derived from a sample of six published papers that reflect a collaborative (interprofessional) approach to education, an argument for a process-driven Dialogical Curriculum Framework is proposed for pre-registration physiotherapy education. A methodology of symbolic interactionism is employed to frame argument from a broad perspective of impermanence and interdependent arising, in the promotion of space for reflection and dialogue to shape learning and professional identity. Learning and emergent professional identity occurs through individuals' social definitions in turn influenced by knowledge and power relationships. The dialogical curriculum seeks to promote a more even distribution of knowledge and power through participation and co-production, in the pursuit of tolerance and coherence to support learning and identity. The parameters and dynamics of the Dialogical Curriculum Framework are represented through the interdependent relationship between four personal and professional attributes, four professional learning themes, and ten professional learning constructs. The processes of space for reflection, open dialogue, participation and symbolic interactionism drive the curriculum, within the context of UK policy and society. The emphasis on the pursuit of person-centred care makes it important for students to make connections with their own and other professions / disciplines to reflect the complexities of contemporary healthcare - an understanding of the 'whole' rather than fragmented parts. Implications for other healthcare professions pre-registration curriculum design is discussed within the context of change in higher education and healthcare professional education. Present day learners are recognised as naturally creative, active problem solvers which combined with process driven curricula provides the opportunity to develop the knowledge, skills, values and behaviours required in the education and learning for practitioners of the future.

Study abroad generates positive learning outcomes for students. However, experiences of learning, and processes, strategies and influences on learning during unaccompanied nursing study abroad are unclear. This hermeneutic phenomenological study therefore investigated student nurse experiences of learning during a study abroad journey in order to explore the phenomenon of learning and the processes, strategies and influences on learning throughout this journey. Twenty student nurses, from the UK and Europe, participated; two semi-structured interviews were conducted per participant (post-return and follow-up). Phenomenological hermeneutical data analysis revealed the phenomenon of learning comprised four themes: ‘experiencing a different reality’; ‘active sense-making’; ‘being with others’ and ‘being changed and transformed’. Findings identify that study abroad was experienced as the liminal space in which learning occurred. Students experienced liminality in this space and the process of learning was triggered by disjuncture. Students took responsibility for learning and undertook active sense-making activities to gain insight. Students struggled to make sense of troublesome experiences, and remained in a stuck place until resolution of troublesome-ness enabled students to cross a threshold into understanding. Threshold concepts in nursing were revealed as particularly troublesome. Learning was influenced by others; this included communitas, communities and communities of practice. Otherness also influenced student learning and position in these communities. Students experienced change and transformation as a result of the learning that had occurred. A postliminal state was attained when troublesome-ness was resolved and students had re-integrated back into their usual reality. These findings offer new practical and theoretical insight into student nurse learning during unaccompanied study abroad journeys and further development of educational policy, practice and research is recommended.

Service improvements in healthcare can improve service provision; make cost efficiency savings, streamline services and reduce clinical errors. However, service improvement alone may not be adequate in improving patient outcomes and quality of care. Complexity of healthcare provision makes service improvement a challenge, and there is little evidence of whether service improvement initiatives change healthcare practice and improve patient care. To equip the nursing workforce with the skills necessary to make service improvements, Higher Educational Institutions (HEI) have developed courses that include service improvement within their pre-registration programmes. However, service improvement is a learned skill, which nurses need to practice in order to become competent in making improvements. In order to explore service improvement in nursing, hermeneutic phenomenology was used to gain an understanding of the lived experiences from student to registered nurse. A purposive sample of twenty participants were selected from an adult pre-registration nursing programme, during their third year. Data was collected using semi-structured interviews in two phases; once when the participants were student nurses and 12 months later when the same participants were registered nurses. Data analysis occurred using a van Manen (1990) approach and the hermeneutic circle to facilitate interpretation and analysis of findings. Four key themes emerged from the data; service improvement in nursing; socialisation in nursing practice; power and powerlessness and challenges in changing practice. Findings showed that the participants underwent processes of professional transformation, becoming empowered and developing resilience in making service improvements from student to registered nurse. Participants achieved this by developing positive, adaptive behaviours. A new ‘Model of Self-efficacy in Service Improvement Enablement’ is presented which explains the participant’s service improvement journey. This new model has relevance for both nurse education and practice, in seeking to improve patient care through service improvements in nursing.

Since the 1990s patient safety has been recognised as a major concern within healthcare worldwide, as well as within the National Health Service (NHS). There is evidence to suggest that contact with healthcare can cause avoidable harm and unnecessary death. In the literature, these significant safety failings have often been linked to the prevailing organisational culture in the NHS. However, the exact nature of this culture and its connection to maintaining patient safety is unclear, despite the reported implementation of strategies to improve patient safety across the healthcare system. As a key staff group within the NHS, nurses have a key role to play in protecting the public and keeping them safe. However, the lack of clarity relating to the links between culture and patient safety initiatives potentially compromises the degree to which nurses can have a positive influence. This qualitative study therefore aimed to better understand, from a nursing perspective, the links between organisational culture and the implementation of patient safety initiatives in one NHS Foundation Trust in England. The following research question provided a focus for the study: ‘How do top-down patient safety initiatives permeate through organisational culture within an NHS Foundation Trust’? A naturalistic inquiry methodology was used to gain an insight into the socially-constructed safety culture within the Trust. A purposive sampling method was used to recruit 16 participants. The sample comprised participants from the Trust executive team, the Trust operational management team, and 2 clinical ward teams, in order to capture staff perspectives from “board to ward”. Data collection included individual interviews and focus groups with the participants about patient safety generally, and their involvement in a selected range of patient safety initiatives including: falls, medications, infection, recognising the sick patient, and pressure sores. Data were collected via direct observation of participants’ practice in addition to a focus group and secondary data analysis of minutes from a range of Trust meetings. Thematic analysis of the data yielded seven themes: cultural consistency; safety initiatives and focus; communication; measurement; development; leading and shaping; and communities of practice. It was also evident from the analysis that only one of the five safety initiatives had fully permeated from board to ward (falls), demonstrating an inefficient flow of information through the Trust. The outcome of the study suggested that “climate”, rather than “culture”, was perhaps a more sensitive indicator of the receptivity of the ward team to the implementation of top-down patient safety initiatives in the NHS Trust studied. It is suggested that rather than focussing on the intangible notion of a “safety culture” as an indicator of safety risk, “safety climate” perhaps offers a more appropriate alternative. Assessing the safety climate of an organisation, and settings within it, offers the opportunity to focus on concrete issues such as nursing staff behaviour and communication mechanisms. This allows identification of organisational barriers to information permeation, and implementation of change. This, in turn, will improve the patient safety climate in the NHS.

Background: It has been suggested that compassion is aspirational, rather than a reflection of the reality of contemporary nursing practice. This notion is reflected through reported negative experiences of nursing care, encountered by individuals across a range of age groups and care contexts. In response, a political and professional reaffirmation has ensued to declare that compassion remains a core philosophy of nursing, although this provides limited articulation of what compassion entails. Furthermore, there is limited empirical research to explore compassion exclusively through the perceptions of individuals who have experienced nursing care, highlighting a gap in existing knowledge. Aim: The aim of the research was to address this gap in knowledge and develop a more comprehensive understanding of compassion in nursing. Specifically, the research aimed to explore compassion, exclusively, through the perceptions of individuals who had personal experience of nursing care. Methodology and Methods: A constructivist grounded theory methodology was implemented, influenced by the theoretical perspectives of symbolic interactionism and social constructionism. The target sample population comprised a group of individuals who were in an established role to contribute to teaching and learning strategies to undergraduate health students within the university setting. Applying a theoretical sampling strategy, data was collected via eleven individual interviews, a focus group discussion with three participants and three additional individual interviews. Data was analysed using initial, focused and advanced coding techniques, supported by constant comparative analysis. Findings: Five data categories were generated from analysis. This comprised the four major categories of Self-Propensity for Compassion, Attributes for Compassion, Socialising for Compassion, Conditions for Compassion and the core category of Humanising for Compassion. Advancing reflexivity to consider these data categories at a more conceptual level identified that compassion was fundamentally characterised by experiences of humanising approaches to nursing care, which were dependent upon the equilibrium of five interrelated elements of compassion. These elements comprised Character for Compassion, Competence for Compassion, Motivation for Compassion, Connecting for Compassion and Action for Compassion. The five elements of compassion were subject to further influence by three overarching principal dimensions of compassion, which comprised Compassionate Self, Compassionate Interactions with Others and Compassionate Situational Contexts. In order to reflect participant perceptions of the complex nature of compassion, a grounded theory was constructed and assimilated into The Model of Compassion for Humanising Nursing Care. The new theoretical insight gained from this model provides a more comprehensive understanding of what compassion in nursing involves, offering an original contribution to the existing knowledge base and a foundation from which to address emerging implications for practice and opportunities for future research.

As part of a high quality nursing student experience within Higher Education there is a need to access the voice of the student. By listening to the students, greater clarity and understanding from the students' perspective is proposed. The focus of this research is within the first year of an undergraduate nursing programme. This thesis gives insight into the experiences and perceptions of undergraduate nursing students' transition into Higher Education and professional transformation, within the first year of a three year proframme. In addition, the research sought to illuminate the participants' personal learning journeys and experiences. There is a dearth of literature addressing various aspects of the first year student experience and minimal literature which represents the student voice. The first year experience is a complex and multifaceted area of study. This complexity is related to the Higher Education organisational processes that are required to enable the student to succeed and the amount of personal investment by each student who enters programmes of learning within a university setting. It has been identified that the first year is the most critical to ensuring that students engage with programmes of learning and achieve both academically and professionally (Trotter and Roberts 2006). To develop insight into the learner's journey a theoretical framework is constructed from within an interpretive paradigm. Hermeneutic phenomenology was selected as a suitable methodology for this research, informed by the work of Max van Manen (1990). The use of hermeneutic phenomenology enable the exploration of participants' experiences. The participants in this research were representative of a typical nursing cohort's profile and, therefore, provided the ideal means of investigating the student nurse experience within the first year. Ten student nurses volunteered to participate in this research and data was collected over a period of one year by use of repeated semi-structured interviews and collection of critical incidents using digital voice recorders. Data was analysed using phenomenological and hermeneutic strategies involving in-depth, iterative reading and interpretation to identify themes in the data. Findings from this research identify that the students have developed skills to survive but there was considerable variation in the student experience which impacted on their motivaton and behaviour. A key finding was the ability of students to develop their own skills of coping to deal with the demands of academic life and those of the practice settings. The skills of self-reliance and self efficacy are evident in the findings and are explored in relation to professional transformation.