Nursing and Midwifery - Doctoral Theses
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Item Communication partners' experiences of using augmentative and alternative communication with persons with severe/profound intellectual disability(University College Cork, 2024) Hanley, Edina; Lehane, Elaine; Martin, Anne-Marie; Dalton O'Connor, Caroline; University College CorkAim: To obtain an in-depth understanding of communication partners’ experiences of communicating with people with severe/profound intellectual disability through augmentative and alternative communication (AAC). Background: Individuals with severe/profound intellectual disability experience significant communication challenges. They require additional support to ensure their potential is recognised and realised and communication needs are met. AAC offers people with complex communication needs, including those with severe/profound intellectual disability, more opportunities, and ways to communicate. The success of AAC relies upon the individual and their communication partners using AAC. However, communication with people with severe/profound intellectual disability through AAC is not straightforward. Many challenges can arise and become barriers to optimising AAC interventions. Given their fundamental role in interacting with and supporting individuals with severe/profound intellectual disability to communicate, understanding communication partners’ experience is essential to promote effective and efficient use of AAC. Therefore, this study explores communication partners’ experiences of using AAC with persons with severe/profound intellectual disability to contribute to knowledge, evidence and to inform practice in this area. Method: A multimethod approach was adopted, where various research methods were used to answer associated research questions at each stage of the research, to address the overall aim (Anguera et al., 2018). A mixed methods systematic review (MMSR) explored communication partners’ experiences of communicating with adults with severe/profound intellectual disability through AAC. A qualitative descriptive approach was utilised to address the gap identified in the MMSR and explored communication partners’ perceptions of their roles and responsibilities in the design, planning and use of AAC with persons with severe/profound intellectual disability. The findings of the qualitative descriptive study indicated that multiple factors influenced communication partners’ use of AAC and identified the need for an integrative review. The integrative review aimed to identify and understand the factors affecting communication partners’ use of AAC. The findings from the qualitative descriptive study and integrative review indicated that the factors influencing use of AAC were interconnected. However, the nature and extent of their interconnections remained unclear. Therefore, a cross-sectional, descriptive, correlational study was developed and undertaken to gain a more nuanced understanding of the factors influencing the intention of communication partners to use AAC with this population. The study was underpinned by a theoretical framework; the Combined Technology Acceptance Model and Theory of Planned Behaviour (C-TAM-TPB), which brought the factors influencing the use of AAC together to test specific hypotheses related to the interconnections between these factors. Survey methods were used to collect data, the survey items tested the constructs of the C-TAM-TPB. Findings: The results of the MMSR and the qualitative descriptive study highlighted the importance of a shared commitment to the communication partnership to support the use of AAC. However, the results of the MMSR indicated that there was a disconnect between communication partners’perceptions of their roles and responsibilities in the design, planning and use of AAC, which posed as a barrier to effective and efficient use. Participants in the qualitative descriptive study took ownership of their roles and responsibilities and respected the roles and responsibilities of other communication partners of the individual they supported. They established a reciprocal relationship to work together and share their expertise to achieve a shared goal, maximise communication through AAC. Despite such commitment, AAC was not optimised to maximise the ability of the individual to communicate. Multiple factors influenced the extent to which AAC was used. Some factors were recurring in each stage of the research and appeared to be interconnected. The integrative review established potential interconnections between the factors influencing the use of AAC, adding to the complexity of factors influencing the optimisation of AAC. The quantitative study identified the nature and extent of the interconnections between the factors influencing communication partners’ intention to use AAC. The findings confirmed those of the literature, where positive relationships existed between the constructs of the C-TAM-TPB. Moreover, some factors carried greater influence than others. Perceived usefulness (p value=0.000 and β=0.253, Wald’s Chi-square χ2=27.5) and perceived ease of use both had a significant impact (p=0.007, β=0.145, Wald’s χ2=7.2) on attitude towards using AAC. Attitude (p value=0.000 and β=0.528, Wald’s χ2=20.8) and perceived behavioural control (p value=0.000 and β=0.332, Wald’s χ2=16.8) had a significant impact on behavioural intention. Conclusion: The study findings indicate that communication partners were committed to communicating with the individual they supported. This commitment was evidenced through attempts to realise their shared goal, maximising communication. Their commitment fuelled their perseverance. However, AAC was not always optimised, and communication partners attempted to reach and realise their shared goal in the context of uncertainty. The extent to which AAC was used by communication partners was impacted by multiple, interconnected factors that must be considered collectively. Factors were both internal to communication partners, such as attitudes and beliefs, while others were environmental. They experienced competing demands that posed as an impediment to their use of AAC.Item Understanding nurses’ experiences of intuition, caring for people with severe and profound intellectual disabilities: an interpretative phenomenological analysis (IPA)(University College Cork, 2024) Conway, Margaret; Mulcahy, Helen; Leahy-Warren, Patricia; O'Mahony, MairinBackground: Nursing intuition is acknowledged as a critical aspect of nursingvpractice. Within the intellectual disability setting, nursing intuition may be a valuable resource in situations where people with severe and profound intellectual disabilities often face communication challenges, which can make it difficult for nurses to obtain accurate information about their needs. However, intuition continues to be theorised and researched without having a recognised position within intellectual disability nursing practice. Aim: The aim of this study is to gain an understanding of nurses’ experiences of intuition, caring for people with severe and profound intellectual disability (ID). Methodology: A phenomenological hermeneutic research design was employed to illuminate the experience of intuition among a purposive sample of eight registered nurses working in residential and day services for people with severe and profound ID. Data were collected through semi-structured interviews which were analysed using Interpretative Phenomenological Analysis (IPA). Ethical approval was obtained from the Ethics Committees at University College Cork, and the Health Service Executive. Findings: Three group experiential themes emerged from the data which were, “being present”, “utilising holistic knowledge” and “articulating intuition into being.” The unique personal experience of being present, characterised intellectual disability nursing intuition. Nurses engaged in transcendent nursing practice, and their intuition was a crucial aspect of this. The physical closeness of nurses to their clients served as a pathway into intuitive presence. Nurses established a connection with individuals though their embodiment, which functioned as an early indicator of client deterioration. The ability of nurses to be empathetic was based on their intuitive presence. Strategies such as reflective practice and continuing education were used to combine intuitive knowledge with professional knowledge to guide a holistic approach to the nursing care of people with severe and profound ID. A shortage of objective terminology hindered nurses in effectively documenting their intuitive concerns, posing a barrier to the practice of nursing intuition. However nurses were found to foster intuitive practice among colleagues. Conclusion and implications: The findings from this study suggest that nursing intuition exists as an essential form of nursing knowledge for participants caring for people with severe and profound ID. The implications are that nurses who rely on their intuition may be the only means by which their clients’ needs and preferences are understood, as well as identifying early signs of deterioration to prevent complications, which is especially vital for this population. Therefore, the retention of nurses in front-line care is vital for establishing and nurturing therapeutic relationships, facilitating effective communication, providing person-centred care and preventing adverse events. The implications of the study also highlight the need to legitimise the intuitive aspects of intellectual disability nursing practice, elevating it as an integral component of professional nursing knowledge that contributes to improved client outcomes and enhanced overall quality of care.Item Implementation of health and social care standards in health and social care services: development and feasibility testing of an implementation support tool(University College Cork, 2023) Kelly Daly, Yvonne; Hegarty, Josephine; O'Rourke, Niamh; Keyes, Laura M.; Health Information and Quality Authority (HIQA); Health Research BoardIntroduction Health and social care standards are complex quality improvement interventions. Standards are typically made up of evidence-based statements that describe safe, high-quality, person-centred care as an outcome or process of care delivery. They involve multiple stakeholders from multiple levels in the health system and apply to diverse services. There is limited evidence to inform implementation strategies specifically tailored to support the implementation of standards. There is a need to apply evidence-based, rigorous and transparent methods when selecting strategies to support the implementation of standards. Researchers have consistently highlighted a research-to-practice gap in this area. This PhD research aimed to develop and test an evidence- and theory-informed intervention to guide the identification of appropriate implementation strategies and the selection of tailored support tools and actions for use when implementing a set of standards. Methods The Medical Research Council (MRC) framework for developing and evaluating complex interventions guided a multi-methods sequential approach. A) Standards were conceptualised by narratively synthesising 12 definitions of standards used by standard-setting bodies internationally. B) The evidence-base was gathered by conducting: a systematic review (n=35 included studies) to identify and describe enablers and barriers to implementing (inter)nationally endorsed standards; and C) a qualitative exploration (focus groups (n=6), individual interviews (n=8)) of individuals’ (n=38) experiences, enablers and barriers to implementing nationally endorsed standards in Ireland. D) These enablers and barriers were used alongside implementation science theory, tools and methodologies to develop a digital intervention. Programme theory guided the development process. The Consolidated Framework for Implementation Research (CFIR), CFIR-ERIC (Expert Recommendations for Implementing Change) matching tool and the Behaviour Change Wheel (BCW) were used to develop a prototype of the content and interactive logic within a digital intervention. E) Co-design workshops (n=3) were held to refine the digital intervention with intended users (n=7). F) A feasibility study was undertaken with end-users (n=14) using a survey that measured acceptability, appropriateness and feasibility. Results A) There was variation in how standard-setting bodies define standards. The commonalities among definitions included the terms ‘quality’, ‘statements’ and ‘performance.’ B) Thematic statements describing enablers (n=22) and barriers (n=24) were created. The most frequently reported enablers related to available support tools, education and shared learning. The most frequently reported barriers related to a lack of knowledge of standards, staffing issues and insufficient funds. C) Six themes were generated from qualitative interviews. Key enablers identified related to teamwork, support tools, leadership and inspections. Key barriers related to workforce issues, a lack of awareness of standards and fear of inspection outcomes. D) Twenty-three enablers and barriers were prioritised using set criteria. E) Iterative feedback led to refinements of the intervention, creating the prototype for the feasibility study. The intervention was entitled SITAS (Selecting Implementation Tools and Actions for Standards). F) SITAS was perceived as acceptable and feasible in preliminary feasibility testing. Conclusion A feasible intervention was developed, enhanced by user involvement. SITAS is a practical digitally enabled intervention that can facilitate bridging the research-to-practice gap. SITAS aims to guide the process of selecting and tailoring implementation strategies to specific contexts, using core concepts of implementation science. Further research is required to undertake formal piloting on SITAS using a larger sample size before spread and scale up.Item The Kidscope Study: an analysis of a community paediatric development clinic set in a disadvantaged area of Ireland(University College Cork, 2024) Buckley, Lynn; Curtin, Margaret; Gibson, Louise; Cornally, Nicola; Harford, Katherine; Irish Research Council; Higher Education Authority; Child and Family Agency; Cork City CouncilBackground: Set in the disadvantaged community of Cork city northwest, Kidscope is the only community paediatric development clinic in Ireland to offer assessment, care, and onward referral within a highly vulnerable area. The complex healthcare intervention provides early developmental assessment and care for children aged zero to six years. Disadvantaged communities often experience a lack of empowerment and limited engagement with services, and high-quality services for children can be inconsistent and limited. Ireland’s disjointed disability system sees children from more affluent communities access health and developmental supports faster through paid private assessment. Kidscope attempts to intercept the gap within the system by providing timely and accessible health and developmental care to vulnerable children. A detailed analysis of Kidscope and its value for supporting the health and development of a vulnerable population was warranted. Methods: Analysis of Kidscope was carried out through a retrospective mixed-methods realist evaluation examining if and how engagement with Kidscope supports the health and developmental needs of vulnerable children. ‘Context (c) + mechanism (m) = outcome (o)’ configurations explained under what contexts, for whom, and how Kidscope achieves this. Underpinned by the Ecological Systems Theory and guided by the Medical Research Council Framework for Complex Interventions, realist evaluation involved three phases: 1. Develop initial programme theories (IPTs), 2. Test IPTs, and 3. Refine programme theory. From 2019 to 2023, five studies tested and refined IPTs using multiple data sources and methods of analysis. Results were collated and analysed in a convergent approach to refine programme theory and develop a set of comprehensive findings to answer the research question. Findings: Ten IPTs were tested and refined through a systematic review of international evidence and four Kidscope-specific empirical studies: a stakeholder analysis, process evaluation, experience and meaning study, and comparison study examining models of care employed in Kidscope and a hospital-based equivalent clinic. Kidscope is set in an area of social disadvantage with higher levels of adversity and complex needs. Families encounter multiple barriers to healthcare access. A long history of community collaboration provides solid foundations for implementation, and contextual elements facilitate delivery: an accessible and welcoming space cognisant of community needs; care delivered over multiple touchpoints; and, embedded practitioner training and education. Mechanisms triggering delivery of child health and developmental support include: utilising and enhancing local expertise through Infant Mental Health (IMH) approaches; relational working; timely and coordinated health and developmental assessment, care, and onward referral; care from a range of specialists; innovative and flexible implementation processes; child and family advocacy; and bridging gaps between services and sectors. Kidscope supports the health and developmental needs of vulnerable children by 1. Developing an innovative and responsive, community-driven child and family model of care, 2. Growing a coalition of IMH-informed child development professionals, 3. Building strong relationships, 4. Meaningfully engaging vulnerable families, and 5. Tackling barriers to highquality healthcare access. Conclusions: Kidscope contributes to breaking the cycle of intergenerational poverty by disrupting the impacts of exclusion to healthcare on child development. By examining interrelationships between context, mechanisms, and outcomes using a realist lens, findings explain how engagement with Kidscope supports the health and developmental needs of a vulnerable population. National healthcare policies promising efficient developmental assessment and integrated care have yet to achieve such goals. The research offers important insights into the health needs and values of a vulnerable population that can be used to thoughtfully examine models of care within contemporary child health practices in Ireland and further afield. Findings provide evidence to support implementing similar models of care across disadvantaged areas to benefit the most vulnerable in society.Item To what extent are Child and Adolescent Mental Health Services engaged in Trauma Informed Practice: an Irish study(University College Cork, 2023) Heffernan, Sinead; Leahy-Warren, Patricia; Drennan, Jonathan; Dalton O'Connor, CarolineBackground: Children and adolescents attending the mental health services are likely to have experienced childhood or intergenerational trauma. International and national mental health policy recommends that services integrate TIP into mental healthcare provision. A lack of research studies exploring the integration of TIP, with this cohort were identified. Method: A descriptive correlational study design utilised a convenience approach to gain a sample from the target population: all CAMHS staff nationally. Data were collected using a psychometrically validated organisational assessment tool. Mostly descriptive, inferential, and some thematic analyses were deployed. Results: Respondents reported low levels of TIP, overall. The majority of respondents were female, community based, clinical staff. Levels of trauma informed therapeutic engagement with service users, and organisational supports for TIP were ascertained from a staff perspective. Results indicated a varied results with therapeutic engagement revealing higher scores than the organisational related areas in CAMHS. Areas that pertained to person centred approaches to consistent care delivery, safety and care planning, and de-escalation were to some extent developed. Gaps in care provision related to language, culturally sensitive care provision, and coproduction including eliciting feedback routinely, communication, flexibility, and staff supports to mitigate vicarious trauma were identified. Further gaps pertained to educating both service users and staff about trauma and its impact on mental health, as well as TIP delivery and evaluation. Overall organisational rather than individual staff factors represented require significant development to achieve TIP. The results of inferential analysis identified relationships between staffs’ levels of satisfaction in current role; which was found to be the strongest predictor of TIP (R2=14.7%, p<0.001), followed by location of role (R2=8.2%, p<0.001) and length of service (R2=3.3%, p<0.040). No relationships were found re: role in CAMH service (p=0.495) and attending TIP training (p=0.840). Thematic analysis found that training was not systematically provided or attended. Gaps in relation to TIP training content, frequency and duration were identified. Discussion: TIP has been described as a humanistic approach to care delivery that recommends approaches that can optimise therapeutic relationships and person-centred care characterised by flexibility, peer supports and collaboration and require further development. Organisational supports for training provision for all CAMHS staff, that is sustainable, evaluated, and accessible, is required. Staff supports that mitigate vicarious trauma for staff also requires further development. An organisational commitment underpinned by resources, strategies to deliver change, guided trauma-informed policy to support TIP, is recommended. Conclusion: CAMHS acute and even more so, community-based services are not currently engaged in TIP, as recommended by mental health policy. The multifaceted nature of TIP requires an organisational approach to guide implementation. The results from this study have identified gaps in relation to organisational support for TIP which can add to the growing knowledge base to support the integration TIP into CAMH Services.