http://hdl.handle.net/1842/153 Wed, 22 May 2013 07:19:57 GMT 2013-05-22T07:19:57Z http://hdl.handle.net/1842/6199 Title: From aspirations to “dream-trap”: nurse education in Nepal and Nepali nurse migration to the UK Authors: Adhikari, Radha Abstract: The migration of nurses is stimulating international debate around globalisation, ethics, and the effects on health systems. This thesis examines this phenomenon through nurses trained in Nepal who migrate to the UK. Since 2000, increasing numbers of Nepali nurses have started crossing national borders to participate in the global healthcare market, particularly in the affluent west. By using qualitative multisited research and in-depth interviews with key stakeholders in both Nepal and the UK, this thesis explores why nurses aspire to migrate, how they fulfil these aspirations, and their experience of living and working in the UK. The thesis begins by examining the historical development of nurse training in Nepal, particularly from the mid 1950s. This period saw profound socio-political transformations, including in the position of women in Nepali society and in the perception of nursing in Nepal. Previously, many families were very reluctant to send their daughters into nursing. By the late 1990s, middle-class women and their families were increasingly attracted to nursing, both as a vocation and as a means to migrate. The thesis explores the rise of private training colleges to meet the increased demand for nurse training, and the new businesses that have grown up around the profession to facilitate nurse recruitment and migration. Around one thousand nurses have migrated to the UK since 2000, and the second part of the thesis presents their experiences of the migration process and of working and settling in the UK. Nurses have faced complex bureaucratic and professional hurdles, particularly after UK nurse registration and work-permit policies changed in 2006. The thesis also highlights how highly qualified nurses with many years of work experience in Nepal have become increasingly deskilled in UK. Frequently sent to rural nursing-homes by recruiting agencies, they create and join new diasporic support networks. Further, many have left their loved ones behind, and experience homesickness and the pain of family separation. Often, they plan for their husbands and children to join them after several years, and the research explores this and the issues faced by their families, as they relocate and adapt to life in the UK. Finally, the thesis makes some important policy recommendations. For Nepal, these relate to greater regulation of nurse training and the brokering of nurses abroad. In the UK, they relate to increasing the flexibility of registration and visa regulations to assist in supporting Nepali nurses' work choices, and to value and utilise their professional skills in the UK better. Fri, 25 Nov 2011 00:00:00 GMT http://hdl.handle.net/1842/6199 2011-11-25T00:00:00Z http://hdl.handle.net/1842/6000 Title: The underlying mechanisms: An investigation of attachment and mentalization within adolescent severe and enduring mental ill health Authors: Fisher, Rebecca Abstract: Background Regarding adolescence developmental psychopathology and the psychological correlates associated with the onset of severe and enduring mental health in adolescence, this thesis proposes that early attachment related experiences underlie the successful ability to regulate emotions, negotiate interpersonal interactions, assess and utilise social support and develop the necessary mentalizing skills for organizing and understanding both the self and others. Insecure attachment and poor reflective function appear to be linked to clinical samples yet the underlying mechanisms for how these constructs affect adolescent psychopathology and subsequent psychological adaptation have still to be examined. Objectives A quantitative cross sectional design was utilised to investigate the following research questions; 1) Is attachment and reflective function directly and indirectly associated with psychological adaptation to mental health difficulties in adolescence? 2) Do emotion regulation, interpersonal difficulties and social support mediate the effect of attachment and reflective function? Methods 75 participants were recruited from three Tier IV Child and Adolescent Mental Health Services in Edinburgh. They were asked to complete questionnaires measuring the variables of mood, interpersonal difficulties, emotion regulation and social support. The Adult Attachment Interview was administered and coded to ascertain the individual‟s attachment classification and was scored to measure their levels of reflective function when considering their childhood experiences. Structural equation modelling (SEM) was used to analyse the data. Results The emergent clinical picture of this sample was one of adolescents with interpersonal difficulties, moderate distress and poor psychological adaptation. The dominant attachment classification was insecure/ dismissing. The observed level of reflective function indicated that participants could refer to mental states but that these references were not made explicit and their understanding of the intentions of others was likely to be general or superficial. SEM analysis demonstrated that reflective function significantly and directly predicted psychological adaptation but not low mood. In contrast attachment demonstrated a significant indirect path to adaptation, being fully mediated by internally dysfunctional emotion regulation strategies. These maladaptive emotion regulation strategies directly predicted low mood and indirectly predicted psychological adaptation. In terms of the social support construct, the discrepancy between the support desired and the support received directly predicted adaption and partially mediated the relationship between reflective function and and psychological adaptation. Discussion The theoretical implications of the results centred on the importance of investigating the underlying mechanisms of attachment and mentalization in the psychological adaptation of adolescents with severe and enduring mental health difficulties. Emotion regulation, interpersonal difficulties and social support were found to play a significant role in low mood and adaptation thus enhancing the current understanding of psychological distress and chronic difficulties for this population. Further clinical implications were discussed concerning the recommendation of promoting and utilizing a mentalization based approach when working with clinical adolescent populations. Sat, 01 Jan 2011 00:00:00 GMT http://hdl.handle.net/1842/6000 2011-01-01T00:00:00Z http://hdl.handle.net/1842/5925 Title: Decision-making processes of weaning from mechanical ventilation: a comparative ethnographic insight into the dynamics of the decision-making environment Authors: Kydonaki, Kalliopi Abstract: Many critical clinical conditions result in respiratory failure and precipitate the use of mechanical ventilation for their management. A prolonged period of mechanical ventilation is costly for both the patient, in terms of adverse effects, and the health care service. Therefore, immediate liberation of the patient from mechanical ventilation and constitution of spontaneous breathing, a process called weaning, is vital. This daily lifesaving practice, on which nurses are taking an increasing role with the introduction of nurse-led protocols, can become complicated requiring the effective use of assessment information through decision-making processes to improve outcomes of care. Most literature on the field fails to address that weaning decisions are affected not only by the nature of the task but also by the characteristics of the decision-maker and the decision environment. This research aimed to study nurses' decision-making processes when managing the weaning of long-term ventilated patients and to explore the impact of the diverse elements of the clinical environment on this intricate practice. An ethnographic approach was used to compare weaning decision-making processes in two different culturally intensive care units (ICU). Participant observation was used to follow the weaning practices of 10 patients in a Scottish ICU and 9 patients in a Greek ICU admitted with respiratory failure due to pneumonia or COPD exacerbation. Nurses were observed in their daily weaning practice and participated in reflective interviews at the end of their shift to extrapolate how they used the information to make their decisions. Semi-structured interviews were, then, conducted with nurses, physiotherapists and medical staff to explore their perceptions on weaning practices and the factors that influenced their decisions and clinical practice. Data were analysed thematically and concept maps were developed from the reflective interviews to analyse nurses‟ decision-making processes. The concept attainment theory was used as a framework to understand nurses' thinking processes. Nurses in all ranges of experience demonstrated a similar decision-making skill, which signifies that this cognitive process is not always related to the level of experience and knowledge. Nurses' weaning care was organised around maintaining a balance of care under the 'wean as able' medical instruction. Inconsistency in the weaning decisions led to a variability of weaning approaches followed for each patient and to long periods of weaning inactivity. Various reasons, related to the working relationships, lack of nurses‟ accountability, lack of support and unstructured information flow, were responsible for the deficiency in sustainable and consistent weaning decisions. In both settings, there was lack of culture to foster a shared decision-making approach in weaning practice and encourage nurses' autonomy in decision-making. This study concluded with proposing a collaborative decision-making framework for weaning long-term ventilated patients, which will involve and appreciate the contribution of all members of the multidisciplinary team. Fri, 25 Nov 2011 00:00:00 GMT http://hdl.handle.net/1842/5925 2011-11-25T00:00:00Z http://hdl.handle.net/1842/4494 Title: ‘Forgotten shopping, lost keys and hearts which forget to beat’: an exploration of nurses’ conceptualisation of dementia Authors: Rhynas, Sarah Janet Abstract: This thesis explores nurses’ conceptualisation of dementia and discusses the relationship between these understandings and nursing practice. Using the reflexive sociological approach of French scholar Pierre Bourdieu, the study seeks to advance practice through the enhancement of theoretical understandings. Data were collected in a range of inpatient clinical areas in Scotland using focus groups, individual interviews and observation. A range of nurses contributed, reflecting views and understandings from inpatient areas run by both general medical and mental health services. Nurses were found to conceptualise dementia in four main ways; as a disease, as a memory problem, as confusion and finally as a journey. These four conceptualisations are addressed in turn and the ways in which they inform and relate to practice are discussed. Limitations to practice arising from the nurses conceptualisations are also highlighted. Dominant approaches to care are outlined throughout the thesis, with the medical model, individualised care, person-centred dementia care and palliative care all being discussed in light of the nurses’ understandings of dementia. Throughout the thesis the work of Pierre Bourdieu shapes the analysis and presentation of data. Relationships within the social world, structures of society and of inpatient settings along with explicit reflection on the personal experiences and position of the researcher inform the work. Concepts of field, capital and habitus permeate the discussion and help to explore issues and understandings from both practice and theory. While literature on specific approaches to dementia care, treatments and relationships between patients, carers and family members form a substantial and growing body of dementia literature, information about nurses and their understandings of dementia has previously been unexplored. This study demonstrates the range of views held by nurses and the influences of education, structures of the clinical setting and ward culture in shaping those understandings. The importance of nurses’ conceptualisations of dementia in shaping their care of patients is demonstrated through the analysis and has the potential to inform and enhance practice development for dementia patients in a variety of inpatient settings. Fri, 01 Jan 2010 00:00:00 GMT http://hdl.handle.net/1842/4494 2010-01-01T00:00:00Z