Talking realistically about nursing: a thematic analysis of nursing course selection interview discourse

This study examines the dialogue within selection interviews for places on a graduate nursing programme The analysis focuses upon the way in which a 'realistic' knowledge of nursing is tested for, and demonstrated through, particular discursive themes These themes reflect a wider social acceptance of accountable rational decision-making It is argued that applicants who are able to draw upon the interpretative resources necessary to justify their nursing course application in these terms are more likely to be evaluated positively     

Shifting the focus: outcomes of care for older people

Internationally there is commitment to work towards eradicating the abuse of older people and to develop services that promote their equality, dignity and human rights. The emphasis on service users is gradually increasing and, along with this, the focus within health and social care policy, service provision and professional practice is shifting. In UK health and social care policy the emphasis on service structure and provision is being replaced by a focus on outcomes for service users, including outcomes which patients themselves evaluate. The focus of UK Adult Protection services is also shifting from intervention to prevention through developing greater understanding of the factors which contribute to abuse, changing attitudes towards entrenched poor care, identifying preventative services and safeguarding vulnerable adults. Nursing literature is also beginning to acknowledge the evolution of an outcomes focus. This paper discusses the shifting emphasis in UK health and social care in the safeguarding of vulnerable people and in nursing practice. It offers an overview of literature on outcomes. The paper then describes a research study which sought to identify outcomes of care for older people living in UK care homes. The outcomes framework developed through the research is offered, along with a discussion of the advantages of an outcome-focused approach to care and some of the remaining challenges. A case example is offered to illustrate an outcomes-focused approach. Finally, the paper draws conclusions on how shifting the focus of care delivery from traditional problem-orientated approaches and ritualized practice towards the outcomes of care that individual older people choose and evaluate for themselves offers potential towards eradicating abuse and neglect in formal care settings.     

The value of involvement from the perspective of service users and carers engaged in practitioner education: not just a cash nexus

This paper presents qualitative findings emergent from a participatory action research (PAR) study focused on developing service user and carer involvement in a university setting. The involvement of these experts by experience in practitioner education for health and social care, and nursing in particular, is now an international phenomenon. Adhering to the philosophy and practices of PAR, the project and the writing of this paper have been collectively produced. Data has been organised using simple thematic analysis into three broad themes accounting for different ways in which participating service users and carers obtain a sense of value from their involvement. We have titled these themes: a more positive sense of self; social and relational benefits; altruism in activism. Drawing on these participant narratives we develop an understanding of the relationship between involvement and reward that does not simply reflect value in payment.     

Exploring inclusion and challenging policy in mainstream education

Education is both a human right in itself and an indispensable mean of a better future. Removing Barriers to Achievement, published by the Department for Education and Skills (DfES, 2004a), highlights its vision for giving children with special educational needs and disabilities the opportunity to achieve their full potential. Chapter two in particular focuses on removing barriers to learning and it is here where the Government focuses, emphasises and justifies the issue of inclusion of children with learning difficulties into mainstream education (DfES, 2004a). The aim of this article is to explore inclusion and simply challenge whether the policy is effective in its purpose by considering educational practice today. It is important that nurses from all fields have some level of understanding regarding the education of children in the community. This is vital to fulfil our role and provide the necessary support to users and families of the service.     

Hearing voices and listening to those that hear them

This paper is concerned with the experience of service users of a mental health Trust. The shared experience of the particular service user group is that of auditory hallucinations. The paper argues that mental health practitioners have, traditionally, not listened effectively to the subjective experience of voice hearing. By creating an environment in which service users can discuss their shared experience, the mental health practitioner can facilitate learning from experience and the development of 'common-sense' management strategies. Such strategies do not demand, or require, text book answers from health care professionals, but emerge from service users, through living with voice hearing. The work is interpreted through Parse's theory of human becoming and Marius Romme's work with 'Hearing Voices'.     

The meaning of nursing home friendships.

This research report on the social networks of institutionalized elderly people describes four types of networks and focuses on resident-resident interaction. Friendship themes of intimacy, social support, reciprocity, and companionship provide a basis for examining similarities in and differences between the network types. Discussion draws on the study results through examination of the meaning of friendship and interpretation of life-span themes.     

Service users and other stakeholders' evaluation of a liaison mental health service in an accident and emergency department and a general hospital setting

Liaison mental health care has been an emerging specialism of mental health nursing in the UK since the early 1990s. Studies have so far looked only briefly at service user evaluation. A qualitative study involving 47 interviews with service user and professional stakeholders was undertaken to determine what is important to stakeholders in a liaison mental health-care service. The largest group of stakeholders interviewed were service users. Analysis of the data was undertaken using the service user interviews to guide the development of themes. The majority of the issues identified were raised by both service users and professionals. The three key themes were, the practicalities of the service including waiting time, the staffing profile and receiving the service, which included issues such as the opportunity to talk and outcomes. The findings provide new information regarding what service users and other stakeholders expect from a liaison mental health service and important areas to consider when offering a satisfactory service.     

User participation in community mental health services: exploring the experiences of users and professionals

Increased user participation and community integration are central aims for contemporary mental health policy in many countries. User participation in community mental health services is developed through practice; from interaction between service‐users and professionals working on the ground level. Despite this, there is a lack of research exploring users’ and professionals’ experiences and views based on the practice of user participation. The objective of this study was to illuminate user participation in a community mental health context based on the experiences of users and professionals within the same services. A qualitative study with an explorative design was applied. Preliminary data analyses based on a field study within three community mental health centres in a Norwegian city lead to our specific focus on experiences of user participation. This theme was explored in individual interviews with 10 users and two group interviews with six professionals. This article is based on the data from these interviews. All informants valued user participation in the service and highlighted the importance of the environment. Users and professionals did, however, highlight interesting issues of user participation from different perspectives. We developed the findings into three main themes: (i) user participation – experiences and preferences, (ii) an environment that promotes user participation and (iii) professional help, responsibility and user participation. Developing service‐users’ influence through participation is important, not only on the political and organisational level, but also in the contexts where users and professionals meet and collaborate. Self‐determination in how to use services means that there are opportunities for receiving support without being subjected to control. Community mental health services which provide flexible, accepting environments with possibilities for both support and challenges may enhance participation and give all users possibilities to have an influence.     

Mental health policy and mental health service user perspectives on involvement: a discourse analysis

AIM: This paper is a report of an exploration of the concept of service user involvement in mental health nursing using a discourse analysis approach. BACKGROUND: Service user involvement has come to be expected in mental health nursing policy and practice. This concept, however, is often applied somewhat ambiguously and some writers call for a clearer understanding of what service users actually want. METHOD: A Foucauldian discourse analysis was conducted in 2005, examining literature and health policies published by the United Kingdom government and service users. The discursive perspectives of both were explored and conceptual themes were generated from the data. FINDINGS: Concepts occurring within government discourse include language relating to service users, the notion of service user involvement and power. Concepts from the service user discourse include power, change and control, theory, policy and practice, and experiential expertise. Differences in perspectives were found within these themes which distinguished government from service user discourses. Greater flexibility in ideas and perspectives was demonstrated by service users, with a seemingly greater range of theoretical underpinnings. CONCLUSION: Greater awareness is needed of the significance of language, of how subtle inferences may be drawn from the rhetorical language of policies, of how these might affect the involvement of service users, and of the implications for the role of mental health nurses. Nurses need to be aware of these tensions and conflicts in managing their practice and in creating a mental health nursing philosophy of 'involvement'. If true 'involvement' is to ensue, nurses may also need to consider the transfer of power to service users.     

Support as a complement, intrusion and right--evidence from ageing and disability support service users in Sweden and Australia

How service users conceptualise their personal support services is under researched, even though this understanding is important for responsive policy development and service implementation. This paper tests the proposition that service users understand formal support in three ways: support is a complement to their other arrangements, an intrusion into their personal life and a right. These three concepts were identified using discourse analysis in a Swedish study of older people wanting in-home support services. To test generalisability of these concepts, they were applied to data from an Australian study of people using disability personal support. The analysis found that the three concepts were core to people's views of their support, although the construction of the concepts differed in the two countries. Service users in Sweden asserted their right to services more forcefully than those in Australia, and they had higher expectations that their support needs would be met. These differences reflect the impact of each country's social policy environment on service users' expectations. The analysis suggests that service users and their families want to control their formal support arrangements to complement their informal care and their life preferences and to minimise the intrusive aspects of formal support. The findings imply that the three concepts have utility for theorising service users' perspectives, informing policy and developing implementation strategies which enhance peoples' quality of life.     

Striving for independence: experiences and needs of service users with life limiting conditions

Title.  Striving for independence: experiences and needs of service users with lifelimiting conditions.
Aim.  This paper is a report of a study to explore what service users with a range of life-limiting conditions identify as their key experiences and needs generally and, specifically, from health and social care services.
Background.  Whilst internationally palliative care has a primary focus on service users who have cancer, there is growing evidence that those with non-cancer life-limiting conditions have similar palliative care needs. The literature has mainly been focused on independence, choice and control at an individual level, with wider influences on the maintenance or attainment of independence ignored.
Method.  A participatory approach was used in 2003–2004, with both the researcher and a group of service users working together in all stages of the study. Twenty-five participants in receipt of support from an acute hospital, primary care, social services and a hospice took part. Face-to-face individual interviews and small discussion groups were conducted and data were analysed thematically.
Findings.  Eight different but interconnected themes were identified. Independence/dependence was an overarching theme, with negotiation between independence and dependence being evident across all themes. This theme and the influence of health and social care services on the experience of living with life-limiting conditions are the focus of this paper.
Conclusion.  Palliative care and practitioners should focus on maximizing independence at both the individual and structural levels. How services for those with life-limiting conditions are provided and relationships with health and social care staff can directly impact on an individual's experience of independence, choice and control.     

Developing sustainable models of interprofessional learning in practice--the TUILIP project

This paper will describe the background and development of the Trent Universities Interprofessional Learning in Practice Project (TUILIP). It will review some of the contributing literature on recent policy initiatives for interprofessional learning (IPL) and in particular the literature that supports the case for IPL to be embedded in the practice learning environment. The impact of IPL on health outcomes is discussed and on team working in practice.The modernisation of the National Health Service in the UK is explained and how the East Midlands Strategic Health Authority has commissioned the TUILIP project that will promote and facilitate the interprofessional skills of students through collaborative working within the practice setting.The TUILIP project is described, in particular, staff development for practitioners, the centrality of service users and the innovative approach of IPL Facilitators in pilot sites across the Trent region.     

A phenomenological hermeneutical method for researching lived experience

This study describes a phenomenological hermeneutical method for interpreting interview texts inspired by the theory of interpretation presented by Paul Ricoeur. Narrative interviews are transcribed. A naïve understanding of the text is formulated from an initial reading. The text is then divided into meaning units that are condensed and abstracted to form sub‐themes, themes and possibly main themes, which are compared with the naïve understanding for validation. Lastly the text is again read as a whole, the naïve understanding and the themes are reflected on in relation to the literature about the meaning of lived experience and a comprehensive understanding is formulated. The comprehensive understanding discloses new possibilities for being in the world. This world can be described as the prefigured life world of the interviewees as configured in the interview and refigured first in the researcher's interpretation and second in the interpretation of the readers of the research report. This may help the readers refigure their own life.     

Service user involvement in nursing, midwifery and health visiting research: a review of evidence and practice

OBJECTIVES: In the UK policy recommends that service users (patients, carers and the public) should be involved in all publicly funded health and social care research. However, little is known about which approaches work best in different research contexts and why. The purpose of this paper is to explain some of the theoretical limitations to current understandings of service user involvement and to provide some suggestions for theory and methods development. This paper draws upon findings from a review of the research 'evidence' and current practice on service user involvement in the design and undertaking of nursing, midwifery and health visiting research. DESIGN: A multi-method review was commissioned by the NHS Service Delivery and Organisation (SDO) Research and Development Programme. The timeframe was April 2004-March 2005. The full report (Ref: SDO/69/2003) and supplementary bibliography are available from: http://www.sdo.lshtm.ac.uk. REVIEW METHODS/DATA: Initial searches of the health and social care literature and consultations with researchers were used to develop a broad definition of the topic area. A service user reference group (26 members) worked with the project team to refine the scope of the review, to set inclusion criteria and develop a framework for the analysis. Systematic searches of the literature were undertaken online and through library stacks (345 relevant documents were identified). Ongoing and recently completed studies that had involved service users were identified through online databases (34 studies) and through a national consultation exercise (17 studies). Selected studies were followed up using telephone interviews (n=11). Members of the service user reference group worked with the research team to advise on key messages for dissemination to different audiences. RESULTS: Information was gained about contextual factors, drivers, concepts, approaches and outcomes of service user involvement in nursing, midwifery and health visiting research, as well as developments in other research fields. Synthesis of this information shows that there are different purposes and domains for user involvement, either as part of researcher-led or user-led research, or as part of a partnership approach. A number of issues were identified as being important for future research. These include: linking different reasons for service user involvement with different outcomes; understanding the relationship between research data and service user involvement, and developing conceptualisations of user involvement that are capable of accommodating complex research relationships. Suggestions for the development of practice include: consideration of diversity, communication, ethical issues, working relationships, finances, education and training. CONCLUSIONS: Because research is undertaken for different reasons and in different contexts, it is not possible to say that involving service users will, or should, always be undertaken in the same way to achieve the same benefits. At a research project level uniqueness of purpose is a defining characteristic and strength of service user involvement.     

Saudi service users’ perceptions and experiences of the quality of their mental health care provision in the Kingdom of Saudi Arabia (KSA): A qualitative inquiry

This paper presents, as part of a larger mixed‐methods design, a study generating a theoretical understanding of issues pertinent to the quality of mental health care in the KSA from the perspective of those using services. Semi‐structured interviews were undertaken with thirty service users admitted to inpatient psychiatric wards, using an interview guide developed by the researchers, based on relevant literature. Findings from the thematic analysis showed five themes: (1) The hospital as a prison: a custody versus care dilemma, (2) quality of interactions between staff and service users, (3) quality of services, (4) staff qualities and (5) suggestions for achieving quality of care. A theoretical model drawing upon Donabedian Health Care Model for Evaluating quality of care and the Andersen Behavioural Model of Health Service Use is evident from the data. Structural aspects of care include staff experience and qualifications and key enablers around social and financial support, service users’ health needs and status and the physical infrastructure and ward rules. These drive processes of care based upon robust rates of interaction between staff and service users and appear central to quality of mental health care in KSA. Quality of mental health care in KSA is manifested by a therapeutic ethos with a high degree of interaction between professional carers and service users, with the former being highly educated, competent, compassionate, with a high degree of self‐awareness, and specialized in mental health. We have uncovered elements of Fanon and Azoulay’s ‘Cultural Originality’ as well as contemporary examples of Goffman’s mortification of the self.     

Involving users in service planning: a focus group approach.

This paper outlines the way in which a focus group approach was used to involve service users in the possible reconfiguration of follow-up services for breast cancer patients at a North London hospital. The focus group was used to identify the priority issues for users and the development of an objective questionnaire, to survey all current service users. Within the National Health Service (NHS) the concept of user involvement has been embodied in contemporary health policy, and has become an important constituent of current policy direction. This study was the first stage of a larger stakeholder project that aimed to involve service users and clinicians in developing a new model of breast cancer follow-up service. From the focus group emerged five key themes around breast cancer follow up. They were: The need for reassurance after the diagnosis of cancer. Continuity of care. Privacy and dignity and other elements of the examination technique. Information and the detection of new symptoms. The opportunity to discuss feelings and worries. In this paper, the nature of breast cancer follow-up services is outlined, and the difficulties associated with such services are discussed. The background to user involvement within the United Kingdom is explored, and the strategies that have previously been used are considered. The practical issues involved in using the focus group approach are examined, and the experience of using such an approach is outlined in this study. The involvement of service users as a key stakeholder in the process of planning change, through a participatory research strategy, ensured that their voices were heard alongside those of both hospital and primary care staff.     

Trust and managerialism: exploring discourses of care

AIM: This paper reports a study that explored the relationship between trust and managerialism through an analysis of professional discourse. BACKGROUND: Managerialism is a distinct set of discourses and practices related to managerial effectiveness, flexibility and consumer responsiveness that have come to characterize debates over the provision of health and welfare services across the developed world. At the same time, trust has attracted increasing academic and political interest. Managerial discourses are critical of healthcare professions and the way they operate. Professional opinions are challenged as representing the interests of professions rather than service users; as a consequence trust is contested. However, where practitioners are both professionals and managers, the boundaries between these discourses become blurred. Moreover, paradoxical development occurs where increasing autonomy for practitioners is accompanied by a strengthening of managerial controls over their activity. METHOD: Discourse analysis was used to explore the text from two genres, academic literature and interviews (n = 17), in the context of community residential services for people with learning disabilities. The study was conducted in 2001. FINDINGS: Two broad themes were identified, each with a number of sub-themes. The first focuses on the relationship between managerialism and trust located around the management of expectations. The second, 'the politics of care', explores the way professional and managerial discourse articulate to produce complementary and contradictory positions. CONCLUSION: The colonization of professional activity by managerial discourse has produced a context where professional activity is defined by a series of managerial imperatives; trust, which was once the product of intimate social activity is now shaped through techniques based on distrust such as audits and quality monitoring. Nevertheless, the persistence of tensions between trust and managerialism suggest an ongoing struggle for professional autonomy in the face of increasing managerial controls.