Nursing

Permanent URI for this collectionhttps://eresearch.qmu.ac.uk/handle/20.500.12289/7188

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An action research study of Palliative Care for people with A Dementia and their carers
(Queen Margaret University, 2009) Smith, Stephen D M.
The objectives of this participatory action research were to: identify the palliative care needs of PWAD and their carers in West Lothian; analyse two dementia care services as they develop practice in the assessment and management of distress for PWAD, and supporting carers; determine implications for practice development and service delivery. Multiple data collection methods were used including; focus groups, interviews, participant observation, reflective accounts, case studies, documentation review, action learning and notes recorded from meetings with staff. The first phase was a dementia palliative care needs assessment. Eight PWAD, 25 carers and 63 service providers participated in interviews and focus groups. Overall findings were that a palliative care approach provided a useful and appropriate framework to understand the needs of PWAD. Recognition of and support for family carers should take a high priority when considering a model for dementia palliative care. More specific needs were identified, these included: the need to develop person centred approaches; enhance the management of pain and distress and enhance individual support for carers. Two services participated in the action phase; a day centre and a hospital ward. Eleven people with a dementia, 28 carers and 86 service providers participated. Services focused on carer support or assessing pain / distress. Carer support findings: implementing an assessment tool enhanced staffs understanding of carers needs; carers preferred flexible and individual support interventions; family carers experienced cumulative factors that restricted access to support. Assessment of distress findings: assessing distress from the behaviour of PWAD was complex. The implementation of the Disability Distress Assessment Tool (DisDAT) identified new evidence that it provided a person centred assessment suitable for PWAD. It was identified that the theoretical concept of relationship centred care, could provide a way of working, that complemented the adoption of a palliative care approach for PWAD, whilst enhancing carer support and assessment of distress practices.
BECOMING A PERSON-CENTRED FACILITATOR OF LEARNING: A participatory action-oriented inquiry exploring the experience of embodying person-centredness by educators working in hospital settings
(Queen Margaret University, Edinburgh, 2024-05-08) Robinson, Betty Ann
Background: Many educators working in the hospital setting are not well-prepared for their role. They rely on the expert teacher-centred model which is not aligned with nor contributing to developing person-centred cultures. As these educators are positioned to contribute to developing and advancing person-centredness, it is imperative they are enabled to become person-centred in their practice. Little is known about how educators transform from the expert teacher-centred approach to a person-centred facilitation approach. This study investigated how educators become person-centred facilitators. Approach and Methods: With a participatory, action-oriented research design informed by four person-centred methodological principles predicated on practice development and relational inquiry, educators in the hospital setting co-investigated their experience of becoming person-centred facilitators. Collective and individual capacity development activities enabled educators to co-create a pathway to embodying person-centredness. Data was analyzed through five phases of relational inquiry infused critical creative hermeneutics. Findings: A conceptual framework representing becoming person-centred emerged and a Roadmap for Becoming Person-centred was developed. Transformation was guided by three principles, Starting with Self, Developing Community & Belonging, and Bumping Against Culture & Inviting Transformation. Becoming occurred intrapersonally, interpersonally, and contextually through moments of discovery, reconciliation, and action. Findings indicate the four person-centred methodological principles, developed into the RACC Model, are effective in providing educational theory and working in person-centred ways. These principles enable educators to contribute to advancing person-centredness within the realities and complexities of the hospital setting. Conclusions and Implications: Educators working in hospital settings can be enabled to become person-centred facilitators by providing them person-centred learning opportunities and support over time. As pedagogy, the four person-centred methodological principles should be used within orientation programs so educators attain competence in educational theory and person-centredness and use these principles within their own practice. As educators embody being person-centred facilitators, they can contribute to advancing person-centredness.
Coming to understand the professional artistry of nursing practice and facilitating its development: A critical creative collaborative inquiry
(Queen Margaret University, Edinburgh, 2020) Frost, Donna Michelle
This thesis explores the concept of professional artistry in nursing practice. In particular, as it was uncovered and understood by nursing professionals working in hospital, primary care and long term care settings in the Netherlands. Despite the many pressures and challenges within the healthcare system some nurses do manage to practise with beauty and graceful skill while nursing in person-centred and evidence-based ways. These nurses demonstrate that effective, beautiful, perhaps even transformative practice is possible. Practice of this kind has been called professional artistry. A collaborative, critical and creative methodology was developed specifically for this study to enable groups of nurses to inquire together using methods that would take account of the embodied, embedded and creative nature of professional practice. This research has demonstrated that professional artistry in nursing can be understood as a set of ontological and praxiological assumptions which are expressed in five patterns of engagement and result in an enlargement of the space for becoming. The patterns of engagement are described as the creation of a sheltered, shared space; being committed to the ideal; working with the parts and the whole; working with the now and the not yet, and, taking or enabling transformative action. This research has furthermore demonstrated that it is possible within busy, real life nursing environments for nurses to engage in an iterative and systematic process of embodied learning through which they can develop shared understandings of their professional artistry, involve their colleagues, patients and other stakeholders in co-creation of these understandings, and experience both perspective transformations and further development of their professional artistry. Iterative inquiry into professional artistry via a critical, creative and collaborative process not only supports the embodied understanding of professional artistry in one’s own practice, but creates the conditions in which it can be further developed.
Constructing spaces of authentic engagement through embodied practice: an exploration of deaf peoples’ and nurses’ experiences of interacting
(Queen Margaret University, Edinburgh, 2021) Dickson, Megan
Background: British Sign Language (BSL) is the visual-spatial language of deaf people in Scotland. For deaf, BSL users all contact with the NHS takes place in a hearing led context where spoken English is the primary mode of communication. Healthcare can therefore be challenging for deaf people to access and engage in. The implicit assumptions of the biomedical perspective, that views deafness as an illness to be ‘cured’, often underpin and shape healthcare practices. In this context, there is a lack of acknowledgement of deaf peoples’ linguistic and cultural status. There has been recognition in healthcare literature that access to healthcare is problematic for deaf people. However, the majority of this literature is informed by the biomedical perspective, privileging positivist approaches to treating deaf people. This has resulted in knowledge that does acknowledge the social world in which deaf peoples’ experiences of healthcare take place. Conceptualising healthcare as a form of social relationship, this research explored nurses’ and deaf peoples’ experiences of interacting with one another. Approach and methods: This research is situated in the critical creative paradigm and underpinned by Gadamer’s hermeneutics and Merleau-Ponty’s philosophy of embodiment. The hermeneutic perspective enabled exploration of participants’ relational and contextual experiences of interacting, and creative methods enabled access to the participants’ and researcher’s embodied knowledge of these experiences. Semi-structured interviews with deaf, BSL users and nurses who had provided care for a deaf person were undertaken over a period of 10 months. A focus group of BSL/English interpreters was also carried out. Findings: The findings revealed that nurses often articulated and embodied predominantly biomedical understandings of what it means to be deaf. Approaching care from this perspective, nurses often struggled to acknowledge or respond to deaf peoples’ visual-spatial ways of being and knowing. Healthcare environments were therefore frequently experienced by deaf people as hearing spaces in which they were systematically disempowered due to the oppression of their visual-spatial nature and language. This created divisive boundaries between deaf people and nurses that limited the potential for an effective nursing relationship to develop. Nurses who displayed qualities of openness and curiosity developed alternative ways of thinking about deafness. These had the potential to transform their approaches to practice that enabled collaborative relationships to develop. Conclusions and implications: This research has demonstrated that healthcare spaces are relational and therefore constructed by the social actions of the people in them. For nurses to construct spaces that are respectful of and embodied deaf culture, the significance of the whole body in developing relational practice must be recognised. Such understanding and knowledge could enable nurses to approach practice with an awareness of how both their own and deaf peoples’ embodied experiences can inform care. This necessitates reflexivity in which nurses recognise and question the assumptions that underpin their practice. Recognising the significance of deaf peoples’ visual-spatial experience and embodied understanding of the world has the potential to contribute to emancipatory and empowering approaches to caring for deaf people. Keywords: deaf, British Sign Language, embodiment, embodied practice, creative hermeneutics
Devolution and nursing workforce policy and planning in the four countries of the United Kingdom 1997-2009
(Queen Margaret University, 2013) Milne, Pauline
This thesis examines how political devolution in the UK impacted upon nursing workforce policy and planning by investigating the following research questions:  What has been the impact of devolution on nursing workforce policy and planning across the four countries of the UK (1997-2009)?  How and why have the approaches to nursing workforce policy and planning changed across the four countries of the UK (1997-2009)? The research methodology used was a mixed methods approach which included semi-structured interviews with 30 stakeholders from the fields of nursing, healthcare policy or workforce planning across the UK. A purposive sampling strategy was adopted and the distribution of interviewees was England (11), Scotland (7), Wales (6) and Northern Ireland (6). A realist review approach to inquiry was taken which involved establishing what works for who, in what circumstances and why? The qualitative data from the interviews was supplemented by analysis of quantitative data on nursing workforce trends and information from the analysis of health policies from the four countries. The key findings include: changing patterns of power and influence in the devolved administrations; continued cycles of ‘boom and bust’ in nursing workforce supply; variable growth in the nursing workforce across the UK; the unwillingness of England to ‘let go’ and the perception by interviewees that some national nursing policies were unimportant. The conclusions were that although devolution enabled greater freedoms in terms of policy and workforce flexibility, just under half of the interviewees reported that devolution had a positive impact upon nursing. There was reluctance from senior nursing leaders to share and learn from good practice across countries and despite the rhetoric from numerous reports around the need to improve nursing workforce planning, there was little evidence of lessons being learned which would have improved the effectiveness of planning the future nursing workforce.
An exploration of how healthful relationships between students and clinical supervisors influence transformational learning: A person-centred inquiry
(Queen Margaret University, Edinburgh, 2020) Mackay, Maria
Background: There is an emerging body of knowledge regarding the influence of person-centred pre-registration curricula on student learning. However, a gap exists in our current knowledge regarding the attributes and foundations of healthful relationships and transformational learning in the context of practice learning. This PhD research based at the University of Wollongong NSW Australia, explored how healthful relationships between students and clinical supervisors influence transformational learning. Approach and Method: The blending of specific aspects of critical theory, person-centred practice research, and transformational learning theory underpinned this research. Embedded within a person-centred methodology, the research explored healthful relationships and their influence on transformational learning in the clinical practice context. Methods included reflection on practice using emoji, the use of Dadirri as a form of contemplation (Ungunmerr 1988) and reflection, critical dialogue and interviews. A creative synthesis of information collected across the PhD journey was undertaken. Findings: The findings from this research revealed the influence of healthful relationships on transformational learning in practice across three connected perspectives: personhood; belonging; and transformation. Information was synthesised to illuminate the crafting of healthful relationships between students and clinical supervisors in the context of practice. Further, understanding emerged of how healthful relationships influenced person-centred transformational learning from the perspectives of Knowing, Doing, Being and Becoming. The discoveries indicate that emotional preparation influences the ability to create healthful relationships that enable person-centred transformational learning in practice. Conclusions and Implications: There is a need for emotional preparation for practice for students and clinical supervisors to enable them to achieve person-centred transformational learning. Respecting personhood and enabling belonging to know self has the potential to lead to the creation of healthful relationships and improved clinical placement experience. Healthful relationships influence person-centred transformational learning by enabling an emotional connection of the mind and heart with an openness to learn. Keywords: curricula, Dadirri, emoji, healthful relationships, nursing education, person-centred, transformational learning.
EXPLORING THE MEANING OF FACILITATION IN PRACTICE DEVELOPMENT IN COLLABORATION WITH REGISTERED NURSES AND HEALTHCARE ASSISTANTS: A PARTICIPATORY RESEARCH STUDY
(Queen Margaret University, Edinburgh, 2025-10) Breslin, Elizabeth
Background This research study aimed to explore the meaning of facilitation in Practice Development (PD). My co-researchers were registered nurses and healthcare assistants (practice co-researchers) working in two residential care facilities in Ireland. PD is an approach to developing person-centred cultures of care grounded in critical social science that integrates collaborative, inclusive, and participatory approaches to achieve person-centred and evidence-based care. Central to PD is person-centred facilitation, which is the focus of my research, examining the meaning of facilitation in the reality of practice. Research Methods Using a person-centred methodological approach, this study was conducted in two residential care facilities in Ireland and underpinned by participatory and emancipatory principles. Research fieldwork was conducted over fourteen months. A range of Practice Development (PD) methods were used, including one-to-one interviews, reflective accounts, observations of practice, facilitation workshops, and informal conversations. These activities were conducted over fourteen months to support engagement and foster trust. A creative hermeneutic data analysis was used to interpret how facilitators experienced and made sense of facilitation in practice. In the later phase, experienced co-researchers joined the analysis process to critically reflect on and deepen their understanding of the emerging outcomes. Research Outcomes In this research, five key elements emerged that illuminate the meaning of facilitation in PD: autonomy, courage, understanding person-centredness, embracing active learning, and flourishing. Person-centred relationships between individuals are underpinned by trust, knowledge of self and others, learning to be creative, having time, and having a supportive space to work together towards a shared purpose in practice.
Exploring the relationship between life experiences and early relapse among imprisoned users of illegal drugs in Oman: A focused ethnography
(Queen Margaret University, Edinburgh, 2020) Al Harthi, Hamida Hamed Said
Background: Illegal drug use is a rising problem that affects Omani youth. This research aimed to study a group of young Omani men who were imprisoned more than once for illegal drug use, focusing on exploring their lifestyle experiences inside and outside prison and whether these contributed to their early relapse and re-imprisonment. This is the first study of its kind from Oman conducted in a prison setting. Methods: 19 Omani males aged 18–35 years imprisoned in Oman Central Prison were recruited using purposive sampling. Focused ethnography was conducted over 8 months to explore the drug-related experiences outside prison and during imprisonment. Face-to-face semi-structured interviews with the participants yielded detailed transcripts and field notes. These were thematically analysed, and results compared with the existing literature. Results: The participants’ voices yielded new insights into the lives of young Omani men imprisoned for illegal drug use, including their sufferings and challenges in prison. These included: entry shock, timing and boredom, drug trafficking in prison, as well as physical and psychological health issues. Overall, imprisonment was reported to have negatively impacted the participants’ health, personality, self-concept, emotions, attitudes, behaviour and life expectations. The participants reported how their efforts to reintegrate into Omani community after release from prison were rebuffed due to stigmatisation and rejection from the society and family. They also experienced frequent unemployment, police surveillance, accommodation problems and lack of rehabilitation facilities. The immensity of the accumulated psychophysiological trauma contributed to their early relapse and reimprisonment. Conclusion: This thesis concludes that imprisonment is largely ineffective in controlling drug use in Oman. Urgent action is required across multiple sectors to improve the lives and prospects of users of illegal drugs within and outside prison to minimise factors contributing to early relapse. Key Words: illegal drugs, drug users, Oman, addiction, Omani culture, prisoners, relapse, re-imprisonment, qualitative research, ethnography
Finding Our Way, Telling Our Stories: A Story-Informed Transformation Toward Person-Centred Culture and Practice after Australia’s Oakden Report: An introduction and critical appraisal in partial fulfilment of the Doctor of Philosophy degree by retrospective publication.
(Queen Margaret University, Edinburgh, 2025-10) McKellar, Duncan
This doctoral study by retrospective publication examines the transformation of health, aged and social care environments from dehumanised and dysfunctional into compassionate, person-centred cultures. The research is grounded, firstly, in my experience as a reviewer of South Australia’s Oakden Older Persons’ Mental Health Service, a profoundly flawed institution whose exposure led to several national inquiries and, secondly, in my subsequent experience as the strategic clinical lead of systemic reforms occurring after the report’s publication. Through immersive, embodied scholarship, involving practice-based learning, reflective practice, and autoethnographic research, this study explores the role of storytelling as a mechanism for culture change. The thesis explores the relationship between storytelling, organisational culture, and person-centred care, synthesising insights from philosophy, theology, and social science. It argues that a story-informed approach—where storytelling and story-listening are embedded in work and care practices—enhances empathy, disrupts power hierarchies, and fosters psychologically safe environments. This principle, alongside the co-designed Culture Framework developed in the Oakden reform process, provides a strategic model for sustainably embedding person-centred values into health, aged, and social care services. The critical appraisal considers theologically informed personalism as an ontology, functioning as a wellspring for a dynamic embodied scholarly practice. It also positions storytelling as an epistemology that humanises care and builds ethical, empathetic, and inclusive cultures. It evaluates the study’s methodological foundation in evocative autoethnography and reflexive scholarship, addressing the ethical complexities of narrating lived experience. The findings affirm that systemic failures, such as those at Oakden, are often rooted in the erosion of personhood and relational care. By offering an applied model of cultural transformation, this thesis contributes new knowledge to the field of person-centred practice, advocating for narrative as a central mechanism in achieving sustainable, compassionate care environments.
How do the characteristics of context influence the work of facilitators when implementing a standardised educational intervention targeting nursing home staff to reduce restraint in dementia care?
(Queen Margaret University, Edinburgh, 2015) Mekki, Tone
This research is part of a larger study - a sequential mixed method education intervention targeting staff in 24 Nursing Homes (NHs) in Norway to reduce use of restraint and psychotropic drugs. Building on a previous successful intervention, we used the Promoting Action on Research Implementation in Health Services (PARIHS) prospectively to combine cluster randomized controlled trial, participatory action research (PAR) and ethnography to design and evaluate the effectiveness of 2 day staff education and 1 hour monthly coaching during 6 months in two rounds (12 x 2 NHs). In my research that is the primary focus of this thesis, four teams of eight facilitators facilitated the intervention and simultaneously participated in PAR to co-construct knowledge of hindering and promoting implementation factors. A 'Creative Hermeneutic Knowledge Co- Production' (CrHeKCoP) model blending paradigmatic and epistemological assumptions from critical and participatory worldviews was created and used in spirals of 10 mini-cycles of actions to co-construct knowledge of the implementation process.
THE INFLUENCE OF THE PRACTICE ENVIRONMENT ON SHARING DECISION MAKING BETWEEN OLDER PERSONS AND NURSES IN RESIDENTIAL AGED CARE: AN AUSTRALIAN PERSON-CENTRED STUDY
(Queen Margaret University, Edinburgh, 2025-05) Marriott-Statham, Kelly
Background: With an ageing population and recent recommendations from the Australian Royal Commission into Aged Care Quality and Safety, there is a need to understand how older persons are enabled to participate in care decisions. While sharing decision making is promoted widely in healthcare, the practice environment plays a key role in shaping how these decisions are made and how older people are included in their care. Aims and Objectives: The aim of this research was to explore how the constructs of the practice environment domain within the Person-centred Practice Framework influence sharing decision making between older persons and nurses in residential aged care. Approach and Methods: Using a person-centred methodological approach, the research utilised emotional touchpoint interviews, observations of practice and practice development methods in a residential aged care facility in Australia. A creative hermeneutic analysis was used with participants to interpret how the practice environment shaped decision making. Findings: Seven components were found to influence the relational connectedness and sharing decision making between older persons and nurses: affirming personhood, reciprocal trustworthiness, time as presence, intentional way of being, negotiating relational boundaries, organisational values in action, and policies in practice. This research contributes a new perspective of sharing decision making as a relational process continuously influenced by people, processes and structures within the practice environment. Conclusions and Implications: This research highlighted the practice environment as key to how decision making occurs between older persons and nurses. To support sharing decision making processes, aged care organisations need flexible policies, power sharing structures, and workforce models that prioritise relationship building. Nurses should be supported to develop emotional intelligence and have the time to connect meaningfully. Creating conditions where older people are respected, heard and genuinely involved in care must be embedded within the elements of the practice environment.
LIVING AND COPING WITH HIV-RELATED UNCERTAINTIES: A CRITICAL REALIST APPROACH
(Queen Margaret University, Edinburgh, 2025-03-12) Tsigkas, Georgios
Background: This research explores the lived experiences of individuals with HIV, focusing on uncertainty and coping through the lens of Critical Realism (CR). While uncertainty and coping have been studied in the HIV field, they have not been examined using a CR approach. Approach and methods: Seventeen participants were interviewed using a semi-structured approach. Field notes and analytic memos supported the data, which were transcribed verbatim and coded using NVivo 12 software. Data analysis followed three CR-consistent stages: identification of demi-regularities (stage 1), abduction or theoretical redescription (stage 2), and retroduction (stage 3). Findings: Four demi-regularities emerged in the first data analysis stage, reflecting the empirical and actual levels of CR reality: social networks, personal identity, understanding uncertainty and coping, and HIV infection-related demiregularity. These were analysed and conceptualised using pertinent theories, setting the stage for retroduction. Retroduction identified two dual generative mechanisms: self-acceptance or self-rejection and societal acceptance or societal rejection. Conclusions and implications: This research demonstrates how selfacceptance or self-rejection and societal acceptance or societal rejection influence uncertainty and coping in the context of HIV. From a CR perspective, social structures shape human agency. Health and social care practitioners, as part of these structures, play a crucial role in influencing uncertainty and coping. Encouraging individuals with HIV to embrace change can facilitate selfacceptance, thereby enhancing coping and reducing uncertainty.
‘Muchness’ as the subjective experience of well-being: a participatory inquiry with nurses
(Queen Margaret University, Edinburgh, 2021) Sanders, Catherine
Background: My interest in muchness was stimulated upon reading a blog which considered quotes from ‘Alice in Wonderland’ identifying what lessons they might offer healthcare today. One such quote was: ‘You used to be much more “muchier”. You’ve lost your muchness’, said the Mad Hatter. Supported by my experiences of working with nurses who reported feeling overworked, undervalued and undermined, I propose that some nursing staff have lost their muchness - their subjective experience of well-being. This impacts on their readiness to develop themselves, their practice and workplace cultures towards person-centredness. Methods: Drawing upon the work of Paulo Freire and Mark Johnson, theoretical and subsequent person-centred and participatory methodological principles were developed. An innovative research method – Virtual Picture Voice, was created enabling nurses internationally to: • Create and share stories of muchness, generating knowledge about muchness as subjective well-being • Participate in the analysis and synthesis of these stories, contributing to the creation of the Muchness Model Version 1 A metasynthesis process, drawing upon wider theoretical evidence, supported the development of the Muchness Model Version 2. Findings: Situated within virtue ethics, the Muchness Model Version 2 advocates a full-life understanding of well-being for nurses: a balance between the pursuit of feeling fulfilled and feeling good. It values the use of embodied and experiential knowledge to inform and evaluate actions towards nurses experiencing muchness and flourishing in the workplace. Conclusions and implications: A holistic approach to the facilitation of well-being should be adopted, that includes individuals and organisations, working at micro, meso and macro levels, to enable nurses to determine what is important/matters to them personally and professionally; how this can be used to inform: their nursing work; their relationships; their workplace contexts towards enhancing their muchness or subjective experiences of wellbeing. Keywords: Arts-informed approaches, Freire, participatory inquiry, person-centredness, Photo-Voice, subjective well-being, virtual methods
Postgraduate nursing education in Nigeria: understanding registered and graduated students’ experiences in their journeys to programme completion or withdrawal
(Queen Margaret University, Edinburgh, 2018) Onwe, Simon Nwigboji
Background: Nigerian nursing education has developed from initially limited numbers of missionary schools to a more substantial expansion of urban, hospital-based institutions since 1945. Postcolonial emancipation sparked the University of Ibadan into opening the first Department of Nursing in Nigeria in 1965. This triggered the creation of further university-based undergraduate programmes across Nigeria, though many hospital-based schools offering diploma level training have also been retained. The first postgraduate nursing programme commenced in 1988 at the Obafemi Awolowo University, followed by the University of Ibadan and the University of Nigeria, Nsukka. These three universities are still the main postgraduate nursing education providers in Nigeria today. The Nigerian Government and professional stakeholders including the Nigerian Nursing and Midwifery Council are concerned by the low graduation rate of nursing students in relation to the standard programme duration of one year for masters’ and three years for PhD programmes (10%), and their relatively high rate of attrition (20%). Objectives; The study seeks to understand the experiences of postgraduate nursing students in Nigeria. Research method: The research participants included registered and graduated postgraduate nursing students, lecturers, and the staff of nursing education coordinating bodies. They were recruited to this study purposively and by snowballing. The research employed a qualitative inquiry method using face-to-face interviews, the methodology being informed by a critical realist worldview with regard to agency and structure. Result: The key findings revealed that the students’ experiences of delay in completing their programme were influenced by student factors (allocation of time between full-time work and full-time study, and sponsorship); lecturer factors (workload and workforce development); policy issues (programme structure and implementation); and social structures and mechanisms in Nigeria. Recommendation: The researcher recommends further studies on the impact of gender on nursing education, the relationship between postgraduate nursing students’ experience and their expectations, and the effect of international partnerships on postgraduate nursing education in Nigeria. He further recommends a review of the postgraduate nursing curriculum. Conclusion: Findings from such studies would further help to improve the students’ experiences.
A realist evaluation of the contribution of Lean Six Sigma to person-centred cultures in a university hospital
(Queen Margaret University, Edinburgh, 2020) Teeling, Sean Paul
Background: Lean Six Sigma, a quality improvement methodology, has been used in healthcare since 2001. Person-centred approaches to healthcare improvement are now widely advocated in political, policy and practice discourse. Literature shows quality improvement practitioners are often unaware of or pay little attention to Lean Six Sigma’s philosophical roots, seeing it less as an organisational philosophy but more as a quality improvement tool for continuous improvement. A lack of fidelity to Lean Six Sigma’s philosophical roots can create a division between person-centred approaches to transforming care experiences and services, and quality improvement methods focusing solely on efficiency and clinical outcomes. There is little research into, and a poor understanding of, the mechanisms and processes through which Lean Six Sigma education influences healthcare staff’s person-centred practice. Aim: To address the question: whether, to what extent and in what ways, Lean and Six Sigma in healthcare contribute to person-centred care and cultures. Design and methods: Realist review identified three potential Context, Mechanism, Outcome configurations (CMOcs) that explained how Lean Six Sigma influenced practice, relating to staff, patients and organisational influences. A realist evaluation explored how staff interacted with a Lean Six Sigma education programme (the intervention). Specifically, the CMOc relating to staff was adjudicated by study participants to determine whether, to what extent and in what ways it influenced person-centred care and cultures. Data collection was informed by person-centred principles and took place through a series of workshops and semi-structured interviews, followed by a review of research participants’ improvement projects outcomes. Findings: Three focused CMOcs, Aspects of Organisational Culture, the Organisation’s Receptivity and Participants’ Self-perception, emerged from the adjudication of the CMOc relating to staff, illuminating the contextual factors (C) that facilitated the outcomes (O) that arose from the underlying mechanisms (M) that were active when the contextual factors (C) were present. Synergies (respect for persons, voice of the customer, staff empowerment and observational studies), an influencer (quality) and divergences (core values, standardisation and first principles) between participants’ Lean Six Sigma practice and person-centred care and cultures were also revealed. Discussion: A return to Lean Six Sigma’s philosophical roots facilitates coherence in the philosophy, intention, methods and outcomes between Lean Six Sigma and person-centred approaches. Their combined use is not only possible but may also be desirable, enabling Lean Six Sigma practitioners to work in ways that support the development of quality, person-centred care that takes account of the outcomes for, and experiences of, patients, their families and staff. Incorporating person-centred principles into the research design, whilst adhering to the principles and rigour of realist evaluation, resulted in a new way of adjudicating CMOcs and novel methods of working with research participants. This study contributes to the evidence base on the study of quality improvement beyond the effectiveness of interventions alone. The findings will be of interest to researchers, policymakers and practitioners globally. Keywords: Lean, Six Sigma, Lean Six Sigma, Process improvement, Person-centredness, Person-centred care, Person-centred cultures, Kaizen.
THE ROLE OF A FACILITATOR IN ENABLING REGISTERED NURSES TO TRANSLATE REFLECTIVE APPRAISAL INTO WORK-BASED LEARNING AND AN EVALUATION OF THE OUTCOMES OF THIS LEARNING
(Queen Margaret University, Edinburgh, 2019) Williams, Caroline Vivien
This research set out to develop a detailed understanding of the role of the facilitator in enabling registered nurses to translate reflective appraisal into work-based learning (WBL). In doing so the research identified contextual issues that impact on WBL, facilitative processes that enable WBL, and outcomes from WBL. A person-centred, action-oriented, participative methodology was developed specifically for this study. It combined a conceptual framework for facilitation (Critical Companionship) with constructs for a critical enquiry. The methodology was operationalised through two year-long action cycles. In each cycle a facilitator/researcher worked in a 1:1 relationship with five registered nurses to facilitate their learning. Each 1:1 session was audio recorded, and a reflective process review was completed. Three times in each action cycle the participants and facilitator/researcher met up as a group to undertake data analysis using a creative reflective approach. The outputs from this were themed by the facilitator/researcher, and the resultant themes and sub-themes were illustrated with extracts from the 1:1 sessions. A reflective synthesis of each theme enabled the development of a model for a Professional Learning Partnership. A Professional Learning Partnership contains a facilitation triad that requires a trusting partnership; activities to maintain stability; and activities to stimulate growth. The facilitation takes place during a professional conversation in a safe space in work. The contextual factors that impact on the learner are their commitment, how safe they feel in work; and how able they are to act. The outcomes for the learners are changes to self, a changed way of being, and professional growth. These lead on to changes to individual practice. This research has added a new methodology to the field of person-centred healthcare research, and a model for a Professional Learning Partnership that contributes to understanding how a facilitator can enable nurses to learn through their work. Key Words: Facilitation; Work-based learning; Professional learning; Person-centred research; Action-oriented methodology;
Sexual expression in persons living with dementia in a nursing home context: A phenomenological inquiry
(Queen Margaret University, Edinburgh, 2020) Rennie, Karen
Introduction: Research shows that sexual expression provides emotional and physical benefits throughout life and does not diminish with age or loss of capacity (Rennie et al. 2017). Older persons, living in care home, including people living with dementia see themselves as sexual beings and with a continuous need and desire to embody sexual expression. However, evidence demonstrates that sexual needs of ‘residents’ living in nursing or care homes are not viewed as an important part of nursing care (Bauer et al. 2013). Sexual expression is often overlooked as an important part of life in persons with dementia and is still considered the most difficult ‘symptom’ of the behavioural and psychological symptoms of dementia (BPSD) model to manage by nurses (Tucker 2010). Aims and Objectives: This study aimed to generate new knowledge on the meaning of sexual expression in persons living with dementia for person-centred nursing practice and theory. This study also aimed to understand more about how sexual expression effects nurses working in care homes and how sexual expression influences the care of persons with dementia. Methodology: Drawing on existential phenomenology, and person-centred theory as well as new principles drawn from the sensuous literature, I had conversations with four persons living with dementia to explore the nature and meaning of sexual expression. I was able to explore this sensitive topic in a dignified and respectful way by working with a rigorous process consent framework that enabled inclusion of adults with incapacity. I observed eleven nurses and carers and had dialogues with them at work to find out about their experiences of sexual expression within caring. Drawing on four existential principles, I was able to produce rich contextualised descriptions of the participant’s experiences of sexual expression. Findings: Findings show that for persons living with dementia, three topics were unconcealed within the phenomena of sexual expression. They were: (1) embodied sensuous-sexuality; (2) meaningful sexual relationships and (3) sexuality and nursing home culture. For the nurses, findings show that the following topics were significant in nurses experiences of caring for persons living with dementia who express themselves sexually: (1) personal values and beliefs on older persons sexuality; (2) cultural norms around sensuous-sexual expression; (3) the ageing body and (4) lack of awareness and education. Finally, I have developed a ‘Sensuous-Sexual Expression Framework’, which is a new practice framework, and an alternative to BPSD, to view sensuous-sexual in persons living with dementia. Conclusions: This is the first study to explore sexual expression which included persons living with dementia living in nursing homes and to gain valuable insights to their experiences of sexual expression. Practically, this study generates new principles for how nurses can provide better person-centred care for persons living with dementia. Academically, this research adds to existing research that challenges the BPSD model and its underpinning ideas and reframes sexual expression as sensuous-sexual expression. Key words: Sexual expression; Persons living with dementia; Person-centredness; Sensuousness; Existential phenomenology; Participatory principles
Sharing decision‐making between the older person and the nurse: A scoping review
(2022-10-09) Marriott-Statham, Kelly; Dickson, Caroline; Hardiman, Michele
Abstract: Background: Sharing decision‐making is globally recognised as an important concept in healthcare research, policy, education and practice which enhances person‐centred care. However, it is becoming increasingly evident shared decision‐making has not been successfully translated into everyday healthcare practice. Sharing decision‐making has strong links with person‐centred practice. Core to person‐centredness and shared decision making, is the need to recognise that as we age, greater reliance is placed on emotion and life experience to inform decision making processes. With the world's ageing population, older persons facing more complex decisions and transitions of care, it is more important than ever it is understood how shared decision‐making occurs. Objectives: This scoping literature review aims to find out how sharing decision making between nurses and older persons in healthcare settings is understood and presented in published literature. Methods: This scoping review utilised the Arksey and O'Malley methodological framework, advanced by Levac et al. Electronic databases and grey literature were searched, returning 362 records which were examined against defined inclusion criteria. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses extension for Scoping Reviews (PRISMA‐ScR). Results: Twenty‐two records met inclusion criteria for the review. Results indicate while shared decision‐making is included in research, education and policy literature, it has not been effectively translated to inform practice and the relationship between a nurse and an older person. The records lack definitions of shared decision‐making and theoretical or philosophical underpinnings. There is also no consideration of emotion and life experience in decision‐making and how nurses ‘do’ shared decision‐making with older persons. Conclusions: The findings demonstrate sharing decision‐making between nurses and older persons is not well understood in the literature, and therefore is not translated into nursing practice. Further research is needed.
Spiritual aspects of nursing: a descriptive study of nurses' perceptions.
(Queen Margaret University, 1992) Waugh, L. A.
This descriptive, exploratory study examines nurses' perceptions of spiritual care. Having reviewed the literature it became apparent that the spiritual dimension can influence health, well-being and quality of life. Moreover, the nursing literature considers spiritual care part of the nurse's role, however, guidelines for its practice are absent. Research on spiritual care, particularly of British origin, is very much in its infance and nothing is known about how British nurses perceive their role in this. A conceptual framework for giving spiritual care using the Nursing Process is, therefore, offered by the researcher, although this still requires testing. The study, believed to be the first of its kind in Britain, ascertain how nurses, working in care of the elderly hospitals in Scotland, perceived spiritual need and spiritual care and professed to have given this care in practice. This was achieved by distributing a purpose designed postal questionnaire to the population of nurses (n=1170) in 1991. A response rate of 67.8% (n=793) was achieved, 58.5% (n=685) of questionnaires being usable. In addition, factors which appeared to influence the spiritual care nurses were identified. Initially clues to possible factors were obtained by conducting a certain statistical analysis using nurses' responses in the questionnaires. Further exploration of factors influencing spiritual care took place through interviewing a sample (n=12) of nurses. Findings revealed that nurses in the larger sample (n=685) seemed able to identify patients' spiritual needs and evaluate the care given, mainly through using non-verbal / indirect verbal cues displayed by patients. Nurses were, however, less willing / able to personally respond to these needs. Whereas for some nurses their reluctance to respond to patients' spiritual needs may have been due to their disclaim of responsibility for spiritual care, for others it seemed to be due to feelings of inadequacy. Charge nurses claiming religious affiliation and working on varied wards in certain geographical locations were most likely to have claimed to have identified patients' spiritual needs. However, it seemed, from the limited sample interviewed, that personal characteristics of the nurse were perhaps more important than the forementioned factors in determining the spiritual care given. Furthermore, factors relating to other professionals, the ward environment and the patient appeared to influence the way in which spiritual care was given to patients. The limitations of the study are acknowledged and the implications of the findings discussed. Given the descriptive nature of the study its prescriptive function is limited which highlights the need for further research in this important area of patient care.
The nature and use of knowledge by district nurses in decision making relating to first assessment visits.
(Queen Margaret University, 2000) Kennedy, C M.
District nurses are the largest group of community nurses in the United Kingdom and an important aspect of their role is the responsibility to assess the health needs of patients at home. To date there has been limited exploration of the knowledge or decision-making underpinning needs assessment in district nursing practice. The aim of this study was to explore knowledge in use by district nurses at the first assessment visit and the relationship of this knowledge to the decisions they make. The inherent difficulties in exploring the knowledge and decision making of experienced district nurses demanded a systematic and interpretative research approach where the impact of the context could be examined. An ethnographic approach was adopted for the study as the focus on perspectives and activities in the natural setting and the substantial reliance on observation of real examples provided a starting point for this study. Eleven district nurses were accompanied on a first assessment visit. Each district nurse was interviewed twice, immediately following the observed visit and then approximately one year later when preliminary data analysis had been undertaken. This approach to the study revealed a breadth and depth of community nursing knowledge that seemed to incorporate an amalgam of theoretical (knowing that) knowledge with practice based (knowing how) knowledge. The study findings depict the range and scope of the knowledge in use by district nurses and challenge the utility of theoretical models which remove knowledge from the context in which it is used and applied. The most striking findings relate to the influence of the context in which the DN/patient interaction takes place and the reflexive character of the assessment process. In particular, the study illuminates the ways in which DNs utilise a range of cues throughout the assessment process. The information search in assessment is often 'paced' to cope with the uncertainty that exists in many of the complex, multifaceted situations encountered by the DN. Understanding assessment as a paced process was linked to making the best judgement at the time of the first visit. A model of district nurse assessment, which seeks to illuminate the process of assessment, is presented. In particular, this model seeks to highlight the reflexive nature of the assessment process. A typology of district nursing knowledge, which conceptualises six dimensions of practice based knowing in district nursing practice, is also presented. Strategies for decision making are revealed through the application of Carroll and Johnson's (1990) theoretical framework. Recommendations are given for future research and the educational and professional context in which DN practice exists. It is suggested that further research should take cognisance of the ongoing nature of assessment in the community setting. A study conducted over a longer period of time, exploring further the impact of the context on the assessment process, seems particularly important. Given the paced approach to needs assessment and the ongoing nature of assessment identified by the study participants, it is suggested that the qualified DN should be contributing to needs assessment on a continuing basis. This recommendation is counter to recent trends in the skill/grade mix in the DN team which emphasise the need to reduce rather than increase the numbers of qualified DNs. Additionally, given the emphasis on family care by the DNs in this study, it is recommended that DNs should record and examine this important area of their work, so that this aspect of the DN role is identified and acknowledged. Finally, the importance of experiential learning depicted by the participants in this study suggests that work-based and problem-based learning approaches may be the most appropriate way in which to teach DN students about assessment. The findings are therefore important for the education of current and future DNs. This study contributes to the knowledge of assessment practice by increasing understanding of the ways DNs work in relation to the first assessment visit. The model of assessment illuminates the process of assessment and the typology aims to provide a conceptualisation of knowledge in use. Furthermore, the ways in which DNs make decisions is revealed. Therefore, the study findings can inform the education of present and future DNs to the potential benefit of patients and their carers.