Issues in the prescribing of psychotropic and psychoactive medication for persons with learning disability: quantitative and qualitative perspectives

The administration of psychotropic and psychoactive medication for persons with learning disability and accompanying mental illness and/or challenging behaviour has undergone much critical review over the past two decades. Assessment and diagnosis of mental illness in this population continues to be psychopharmacological treatment include polypharmacy, irrational prescription procedures and frequent over-prescription. It is clear that all forms of treatment including non-pharmacological interventions need to be driven by accurate and appropriate diagnoses. Where a psychiatric diagnosis has been identified, it greatly aides the selection of appropriate medication, although a specific medication for each diagnosis, as was once hoped, is simply no longer a reality in practice. Part one of the present thesis seeks to address many of the current issues in mental health problems and pharmacological treatment to date. The author undertook a drug prevalence study within both residential and community facilities for persons with learning disability within the Mid-West region of Ireland in order to ascertain the current level of prescribing of psychotropic and psychoactive medications for this population. While many attempts have been made to account for the variation in prescribing, little systematic and empirical research has been undertaken to investigate the factors thought to influence such prescribing. While studies investigating the prescribing behaviours of General Practitioners (GP's) have illustrated the complex nature of the decision making process in the context of general practice, no similar efforts have yet been directed at examining the prescribing behaviours of Consultant Psychiatrists. Using The Critical Incident Technique, the author interviewed Consultant Psychiatrists in the Republic of Ireland to gather information relating not only to their patterns of prescribing for learning disabled populations, but also to examine reasons influencing their prescribing in addition to several related factors. Part two of this thesis presents the findings from this study and a number of issues are raised, not only in relation to attempting to account for the findings from part one of the thesis, but also with respect to implications for improved management and clinical practice.

Studies relating to the population dynamics of the European badger (Meles meles) in Ireland

European badgers (Meles meles) are an important part of the Irish ecosystem; they are a component of Ireland’s native fauna and are afforded protection by national and international laws. The species is also a reservoir host for bovine tuberculosis (bTB) and implicated in the epidemiology of bTB in cattle. Due to this latter point, badgers have been culled in the Republic of Ireland (ROI) in areas where persistent cattle bTB outbreaks exist. The population dynamics of badgers are therefore of great pure and applied interest. The studies within this thesis used large datasets and a number of analytical approaches to uncover essential elements of badger populations in the ROI. Furthermore, a review and meta-analysis of all available data on Irish badgers was completed to give a framework from which key knowledge gaps and future directions could be identified (Chapter 1). One main finding suggested that badger densities are significantly reduced in areas of repeated culling, as revealed through declining trends in signs of activity (Chapter 2) and capture numbers (Chapter 2 and Chapter 3). Despite this, the trappability of badgers was shown to be lower than previously thought. This indicates that management programmes would require repeated long-term efforts to be effective (Chapter 4). Mark-recapture modelling of a population (sample area: 755km2) suggested that mean badger density was typical of continental European populations, but substantially lower than British populations (Chapter 4). Badger movement patterns indicated that most of the population exhibited site fidelity. Long-distance movements were also recorded, the longest of which (20.1km) was the greatest displacement of an Irish badger currently known (Chapter 5). The studies presented in this thesis allows for the development of more robust models of the badger population at national scales (see Future Directions). Through the use of large-scale datasets future models will facilitate informed sustainable planning for disease control.

The lived experience of Irish diocesan priests. A qualitative study of clerical identity, obedience and celibacy.

The main aim of this thesis is to document and explore the lived experience of Irish diocesan priests and former priests, in order to explore the reality of diocesan priesthood in contemporary Ireland, and to investigate how, if at all, diocesan priesthood has changed in Ireland during the past fifty years. It sought to do this by interrogating the stories of thirty-three diocesan priests and former priests, and by placing their individual stories within the broader context of Irish society and the Catholic Church, during the fifty-year period, 1962–2012. The research focused on three core areas of priesthood – identity, obedience, and celibacy – and it addressed the following questions. First, how do Irish diocesan priests understand their priesthood and how has this understanding changed over time, if at all? I will argue that three paradigms of priesthood co-exist in the contemporary Irish Church, and that each of these models corresponds with a distinct period in contemporary Irish Church history. I will also demonstrate the existence of underlying similarities in the cultural practice of priesthood that transcend the different generations of priests. Second, how do Irish diocesan priests negotiate their priesthood within a large and complex institution? My study suggests that Irish diocesan priests are typically loyal and obedient. However, they are not necessarily subservient. Third, how do Irish diocesan priests understand and experience celibacy in their day-to-day lives? My study demonstrates that celibacy is typically understood and experienced along a continuum, ranging from total acceptance to total rejection, with most priests somewhere in between. Fourth, I will argue that while priests are experiencing many difficulties in their lives, there is insufficient evidence from the present study to indicate they are experiencing a crisis.

Lower extremity amputation in people with diabetes: Trends and determinants

Introduction: The prevalence of diabetes is rising rapidly. Assessing quality of diabetes care is difficult. Lower Extremity Amputation (LEA) is recognised as a marker of the quality of diabetes care. The focus of this thesis was first to describe the trends in LEA rates in people with and without diabetes in the Republic of Ireland (RoI) in recent years and then, to explore the determinants of LEA in people with diabetes. While clinical and socio-demographic determinants have been well-established, the role of service-related factors has been less well-explored. Methods: Using hospital discharge data, trends in LEA rates in people with and without diabetes were described and compared to other countries. Background work included concordance studies exploring the reliability of hospital discharge data for recording LEA and diabetes and estimation of diabetes prevalence rates in the RoI from a nationally representative study (SLAN 2007). To explore determinants, a systematic review and meta-analysis assessed the effect of contact with a podiatrist on the outcome of LEA in people with diabetes. Finally, a case-control study using hospital discharge data explored determinants of LEA in people with diabetes with a particular focus on the timing of access to secondary healthcare services as a risk factor. Results: There are high levels of agreement between hospital discharge data and medical records for LEA and diabetes. Thus, hospital discharge data was deemed sufficiently reliable for use in this PhD thesis. A decrease in major diabetes-related LEA rates in people with diabetes was observed in the RoI from 2005-2012. In 2012, the relative risk of a person with diabetes undergoing a major LEA was 6.2 times (95% CI 4.8-8.1) that of a person without diabetes. Based on the systematic review and meta-analysis, contact with a podiatrist did not significantly affect the relative risk (RR) of LEA in people with diabetes. Results from the case-control study identified being single, documented CKD and documented hypertension as significant risk factors for LEA in people with diabetes whilst documented retinopathy was protective. Within the seven year time window included in the study, no association was detected between LEA in patients with diabetes and timing of patient access to secondary healthcare for diabetes management. Discussion: Many countries have reported reduced major LEA rates in people with diabetes coinciding with improved organisation of healthcare systems. Reassuringly, these first national estimates in people with diabetes in the RoI from 2005 to 2012 demonstrated reducing trends in major LEA rates. This may be attributable to changes in diabetes care and also, secular trends in smoking, dyslipidaemia and hypertension. Consistent with international practice, LEA trends data in Ireland can be used to monitor quality of care. Quantifying this improvement precisely, though, is problematic without robust denominator data on the prevalence of diabetes. However, a reduction in major diabetes-related LEA rates suggests improved quality of diabetes care. Much controversy exists around the reliability of hospital discharge data in the RoI. This thesis includes the first multi-site study to explore this issue and found hospital discharge data reliable for the reporting of the procedure of LEA and diagnosis of diabetes. This project did not detect protective effects of access to services including podiatry and secondary healthcare for LEA in people with diabetes. A major limitation of the systematic review and meta-analysis was the design and quality of the included studies. The data available in the area of effect of contact with a podiatrist on LEA risk are too sparse to say anything definitive about the efficacy of podiatry on LEA. Limitations of the case-control study include lack of a diabetes register in Ireland, restricted information from secondary healthcare and lack of data available from primary healthcare. Due to these issues, duration of disease could not be accounted for in the study which limits the conclusions that can be drawn from the results. The model of diabetes care in the RoI is currently undergoing a re-configuration with plans to introduce integrated care. In the future, trends in LEA rates should be continuously monitored to evaluate the effectiveness of changes to the healthcare system. Efforts are already underway to improve the availability of routine data from primary healthcare with the recent development of the iPCRN (Irish Primary Care Research Network). Linkage of primary and secondary healthcare records with a unique patient identifier should be the goal for the future.

Anticipatory vigilance: A classic grounded theory of risk reduction and management in the perioperative setting

This research aimed to investigate the main concern facing nurses in minimising risk within the perioperative setting and to generate an explanatory substantive theory of how they resolve this through anticipatory vigilance. In the context of the perioperative setting, nurses encounter challenges in minimising risks for their patients on a continuous basis. Current explanations of minimising risk in the perioperative setting offers insights into how perioperative nurses undertake their work. Currently research in minimising risk is broadly related to dealing with errors as opposed to preventing them. To date, little is known about how perioperative nurses practice and maintain safety. This study was guided by the principles of classic grounded theory as described by Glaser (1978, 1998, 2001). Data was collected through individual unstructured interviews with thirty seven perioperative nurses (with varying lengths of experiences of working in the area) and thirty three hours of non-participant observation within eight different perioperative settings in the Republic of Ireland. Data was simultaneously collected and analysed. The theory of anticipatory vigilance emerged as the pattern of behaviour through which nurse’s deal with their main concern of minimising risk in a high risk setting. Anticipatory vigilance is enacted through orchestrating, routinising and momentary adapting within a spirit of trusting relations within the substantive area of the perioperative setting. This theory of offers an explanation on how nurses resolve their main concern of minimising risk within the perioperative setting. The theory of anticipatory vigilance will be useful to nurses in providing a comprehensive framework of explanation and understanding on how nurses deal with minimising risk in the perioperative setting. The theory links perioperative nursing, risk and vigilance together. Clinical improvements through understanding and awareness of the theory of anticipatory vigilance will result in an improved quality environment, leading to safe patient outcomes.

Stair na Gaeilge i gContae Thiobraid Árann 1700-1901

Stair na Gaeilge i gCo. Thiobraid Árann i rith na tréimhse 1700-1901 atá á ríomhadh sa tráchtas seo. Tar éis a cúlra agus a comhthéacs a shuíomh i gCaibidil a hAon, déantar scríobhaithe an cheantair a áireamh, fara tráchtaireacht orthu, i gCaibidil a Dó. I gCaibidlí a Trí agus a Ceathair, féachtar ar thionchar na hEaglaisí Caitlicí agus Eaglais na hÉireann (i measc eaglaisí Protastúnacha eile) ar an dteangain. I gCaibidil a Cúig, faightear spléachadh ar ghnéithe éagsúla de shaíocht an chontae, ag tabhairt léargais ar tháirgí na scríobhaithe, ar leabhair a clóbhualadh sa réigiún, agus ar fhilí móra na háite, leithéidí Liam Daill Uí Ifearnáin, ag sonrú limistéir faoi leith, an t-oirdheisceart, mar shampla. Léirítear éifeacht na gcumann Gaelach agus na ndíograiseoirí iomadúla a bhain leo. Ábhar suime, leis, feidhm na Gaeilge sna cúirteanna dlí. Tugtar faisnéis i gCaibidil a Sé ar fhianaise cuairteoirí ar an Ghaeilge mar urlabhra i dTiobraid Árann. Is anseo chomh maith a deintear anailís ar Dhaonáirimh na mblianta 1861-1901, le mórchuid adhmaid á baint as ceann 1901 go háirithe. Breactar as ainmneacha sagart agus múinteoirí le Gaeilge, agus tráchtar ar aicmí suntasacha eile, na póilíní agus na saighdiúirí a raibh an teanga sin ina mbéal acu. Tugtar le chéile dá réir na snáithíní difriúla eolais ar an dúiche ar bhealach nár tharla cheana don gcontae casta fairsing seo le haghaidh na tréimhse atá idir lámha ag an saothar.

A nation preferring visions: moving statues, apparitions and vernacular religion in contemporary Ireland

This thesis examines important issues of Irish vernacular Catholicism, Irish religious and cultural identities, the impacts of modernity plus socio-religious and economic change on traditional religiosity, sacred landscape and topophilia, religious material culture, folk and individual creativity, gender roles and expectations, and devotional subcultures through the vehicle of Marian apparitions and their aftermath in the Republic of Ireland in the late 20th and early 21st centuries. This thesis examines in detail five Irish Marian shrines as case studies; Knock shrine (Co. Mayo), Ballinspittle and Mitchelstown grottoes (Co. Cork), Mount Melleray grotto (Co. Waterford) and the Marian shrines of Inchigeela in West Cork and the attached houses of prayer. Key themes include; vernacular religious theory; the nature of Irish indigenous Catholicism; local, global and transnational trends in contemporary Irish devotional life; areas of individual creativity, fluidity and agency in Marian devotion; and the vital role and influence of material culture in and on local and individual religiosity.