Paramedics are responsible for the care of patients requiring emergency assistance in the out of hospital setting. These health care providers need to make many decisions during the course of an emergency call. This thesis on paramedic clinical decision-making includes two studies, intended to determine which decisions paramedics make that are most important for patient safety and clinical outcome, and what thinking strategies paramedics rely on to make decisions. Forty-two decisions were found to be most important for outcome and safety. The highest decision density of an emergency call is during the on-scene treatment phase. Paramedics use a mix of thinking strategies, including rule out worst scenario, algorithmic, and exhaustive thinking. The results of these studies have implications for future research, paramedic practice and training.

Background: In hospital critical-care and emergency settings, non-Invasive ventilation (NIV) is increasingly used in neonatal and paediatric patients as an alternative to invasive positive pressure ventilation (IPPV). Critically ill children and babies may need transfer to higher levels of care, but the emergency transport setting is lagging behind the hospital sector in terms of availability of NIV. Aim and objectives: The goal of this study was to assess the evidence on the safety and effectiveness of NIV in children during transportation. Safety outcome measures were intubation or escalation of ventilation mode (during and soon after transport) and adverse event (AE) occurrence during transport. Effectiveness outcome measures related to improvement in clinical parameters during transfer. Methods: A systematised review of the literature was conducted, based on searches of MEDLINE via PubMed, EMBASE (via Scopus), Cochrane Central Register of Controlled Trials (CENTRAL), African Index Medicus, Web of Science Citation Index and the World Health Organisation Trials Registry (ICTRP). Two reviewers independently reviewed all identified studies for eligibility, with an initial screening round followed by a full-text review of potentially relevant articles. The quality of studies meeting inclusion criteria was evaluated using an adapted quality assessment tool developed for this study. Results: A total of 1287 records were identified; of these, 12 studies met inclusion criteria. Following quality assessment, eight studies were included and four studies were excluded. There were no randomised controlled trials, quasi-randomised controlled trials or non-randomised studies of intervention, to answer the research question. The included studies were all observational in design: seven studies (n= 708) evaluated in-transport use of continuous positive airway pressure (CPAP) and one study (n=150) reported on use of high-flow nasal cannula (HFNC) in children during transport. During transport on NIV, 3/858 (0.4%) patients required either intubation (1/708; 0.1%; CPAP studies) or escalation of mode of ventilation (2/150; 1%; HFNC study). In the 24 hours following transfer, 63/650 (13%) of children transferred on NIV, were intubated. The odds of intubation within 24 hours were significantly higher for CPAP transfer 60/500 (12%) compared with HFNC 3/150(2%): OR (95% CI) 6.68 (2.40 - 18.63), p=0.00003. Adverse events, where reported, were found to occur in 2-4% of NIV transports, with use of BVM in 8/334 (2%), desaturation episodes in 9/290 (3%), apnoea in 11/290(4%) and administration of CPR in 0/290 (0%) cases being described. There was insufficient reporting of change in vital signs or clinical condition during transport for meaningful analysis. Conclusion: This study is the first systematised review indicating that NIV use in children during transport is likely to be safe. From the low-reliability evidence available, it was calculated that NIV use in children during transport would result in a 0.4% rate of intubation or escalation during transport and an in-transport adverse event rate of 2-4%. There was insufficient evidence to comment on clinical effectiveness of NIV during transfer. Following NIV transfer, 13% of patients were intubated within 24 hours, with significantly higher odds of intubation in children transported on CPAP compared with HFNC. Recommendations: Further research is needed in order to make firm recommendations regarding the safety and effectiveness of NIV during transport of children. A recommended minimum data set, for the standardised reporting of observational studies of paediatric NIV use during transport, is suggested. It is recommended that transport databases and registries are expanded to include NIV details as well as information regarding the presence or absence of pre-specified adverse events during transport.

Schizoaffective disorder has routinely exhibited poor outcomes related to diagnostic accuracy and reliability. These pitfalls have been linked to the conceptual nature of Schizoaffective Disorder’s combined psychotic and affective symptoms. Clinicians likely perceive the psychotic components of Schizoaffective Disorder as more severe than the affective symptoms, and have demonstrated a bias toward misdiagnosing Schizoaffective Disorder as Schizophrenia. Thus, the present study sought to examine the clinical conceptualizations of Schizoaffective Disorder compared to Schizophrenia, Bipolar Disorder with psychotic features, and Major Depressive Disorder with psychotic features. The participants were clinicians recruited via email and randomly assigned to either select symptoms from a predetermined criteria list (Recognition group) or to freely list features of the disorders based on their own mental representations (Unprompted group). Participants’ conceptualizations of Schizoaffective Disorder were not entirely congruent with DSM-5 criteria; they conceptualized it as less psychotic than Schizophrenia and less affective than the two mood disorder tasks. Schizoaffective Disorder exhibited the lowest proportion of accurate endorsements, and Schizophrenia had the highest proportion. We hypothesized that Schizoaffective Disorder would have the most overextension endorsements because of its fuzzy boundaries, but Schizophrenia had the highest instead. The Recognition Group outperformed the Unprompted Group overall, which can be explained by the availability heuristic. This study’s findings support the notion that Schizoaffective Disorder’s poor diagnostic outcomes are possibly related to clinicians’ conceptualization of the construct, or that its current diagnostic formulation is not congruent with what clinicians observe in clinical settings.

Due to the increasing demand from teaching institutions and the General Dental Council to provide dental students with accurate assessment and feedback, the focus of this thesis is to evaluate and improve assessment and feedback at Dundee Dental School. The aim is to determine and appraise assessment tools used in evaluating the clinical skills of dental students in laboratory setting. In addition, the purpose of this thesis is to further develop the assessment tools to provide valid and reliable assessment and feedback on students’ performance. Dental students practise clinical procedures in clinical skills laboratories which are evaluated by qualified staff. Effective evaluation should be valid (accurate and reliable) and produce consistently useful feedback. In this thesis, assessment of experienced (senior) examiners demonstrated, unrepeatable (intra-examiner) and reproducible (inter-examiner) evaluation of class II amalgam cavity and full veneer gold shell crown preparations in a clinical skills laboratory (Chapters 3 and 4).Further assessment of a wider group of additional teaching staff also demonstrated poor levels of intra-examiner reliability (repeatability) and inter-examiner reliability (reproducibility) (Chapter 4). Concentrating on the senior examiners, consistent methods, including the use of novel tools, were then devised and tested to improve intra-examiner repeatability and inter-examiner reproducibility. These methods also included feedback sheets which served to provide feedback for students (Chapter 5). Grades awarded from the best senior examiner who had the highest level of intra- and inter-examiner repeatability and reproducibility, respectively, were then tested against known developed standard criteria as well as actual preparations to establish the validity of these grades (Chapter 6). The checklist is the most common assessment method which is used within the Clinical Skills Laboratory in Universities. From five consistent methods, new checklists and reliable tools were established and tested again to demonstrate improved validity and reliability of awarded grades as well as feedback consistency (Chapter 7). This process now requires further testing with another cohort of preparations to affirm its usefulness. The new cohort should include tooth preparations by both novice and expert operators to reflect a greater range of abilities and thus test the assessment process more rigorously.

Background: Postpartum haemorrhage (PPH) is the leading cause of maternal death worldwide. For every woman that dies, 20 or 30 more will experience morbidity. Severe PPH is increasing and is the leading cause of severe maternal morbidity in the UK. Rapid recognition of PPH is essential, but concealed bleeding, underestimation of blood loss and a failure to appreciate the physiological effects of blood loss, lead to delays in recognition and treatment. Experts believe that most deaths from PPH could be avoided by earlier diagnosis, but there is a lack of evidence on how to achieve this. Aims: To explore the experiences of those involved in evaluating blood loss during childbirth; and to develop and test a theory of blood loss evaluation and PPH recognition, as a prerequisite to developing strategies to support earlier diagnosis. Study Design: A sequential, exploratory mixed methods design was used. Methods: Qualitative methods included 8 focus groups and 19 one-to-one semi-structured interviews, conducted with 50 participants. These included: women and their birth partners (recruited from Liverpool Women's Hospital); and health professionals (midwives and obstetricians recruited from Saint Mary's Hospital, Manchester). A purposive sampling strategy was used to recruit women, who had experienced vaginal birth with or without PPH, and health professionals, with varying levels of experience in blood loss evaluation and PPH management. A snowball sampling strategy was used to recruit the birth partners of women participants. Phase one was completed from June to September 2014. All discussions were audio-recorded and transcribed verbatim. Data were managed using NVivo 10 qualitative data analysis software, which also supported the Framework approach to analysis and interpretation. Quantitative methods were used in phase two and involved 10 midwives and 11 obstetricians, recruited from Liverpool Women's Hospital, during February and March 2015. Two scenarios, one of fast and one of slow blood loss, were presented to the sample using clinical simulation with the NOELLE® childbirth simulator, in a pilot, randomised, cross-over study. Participants also completed three questions about the use of the NOELLE® mannequin for these types of scenarios. IBM SPSS Statistics version 23 software was used for quantitative data management and to estimate descriptive statistics. Numerical crossover data were copied into StatsDirect software, to perform the crossover analyses. Results: Women and birth partners were very perceptive to blood loss but felt ill-prepared for the reality of bleeding, with many experiencing negative emotional responses to both PPH and the lochia. Non-verbal communication from staff was used by women and their birth partners to interpret the seriousness of their blood loss. Health professionals: Recognition of PPH mainly occurs as an automatic response to the speed of blood flow. Volume of blood loss is often ascertained and used retrospectively after a PPH diagnosis, to validate the intuitive response and to guide and justify on-going decisions. This was confirmed by the simulation studies, where treatment was initiated at 100ml or less in all blood loss scenarios. Fast blood loss was more likely than slow blood loss to elicit a PPH response, despite volumes in the two groups being similar. Formal quantification of blood loss is not used routinely in practice. When it is used, values are often unofficially normalised to reflect health professionals' perceptions of the woman's clinical condition. Tools introduced to aid diagnosis, such as blood collection bags, routine weighing and the use of early warning scores, are not routinely used in the immediate post-birth period, especially if the woman and her blood loss are perceived to be normal. The tools are again used to validate intuitive feelings about blood loss and maternal condition. When they are used, the values are often modified if they contradict professional judgement. Conclusions: Women and birth partners want more information, open communication, and on-going support, to minimise the emotional impact of blood loss. For health professionals, the speed of blood loss is the crucial factor in PPH recognition rather than an accurate assessment of the volume of blood loss. The amount of visible blood is generally not initially interpreted as a volume, but is used to compare current blood losses to those previously witnessed. Experience therefore plays a crucial role in the decisions of whether blood loss is considered normal or excessive. Formal quantification of blood loss and regular recording of physiological observations do not occur routinely in the immediate post-birth period. Therefore, women with insidious blood loss can have delayed PPH diagnosis because they have a normal blood flow and exhibit minimal physiological changes, due to the compensatory mechanisms of shock. Often such women need to exhibit outward signs of physiological compromise, such as fainting or feeling unwell, before their physiological observations and blood loss are formally re-evaluated. Education of health professionals should highlight the common errors of judgement made during blood loss evaluation and provide feedback on cases of delayed recognition. Future research should examine normal postnatal bleeding in the hours following birth, and create visual aids for women to self-diagnose insidious blood loss. Training should focus on the skills of PPH recognition, particularly those with insidious blood loss and postnatal physiological assessments. Novel tools such as the shock index should be considered and evaluated as tools of assessment.

The purpose of this study was to validate the problem behavior evaluation section of an expert system computer program, Class.BO. Class.BO was developed to assist special education personnel in determining whether students qualify for special education services as behaviorally disordered/severely emotionally disturbed students. The subjects were six Utah who regularly individuals from the state of 1) work with behaviorally disordered/severely emotionally disturbed students and 2) participate in multidisciplinary assessment teams. Three of the subjects were special educators, and three were school psychologists. Specifically, this study investigated the impact of five behavioral factors on the subjects' ratings of the seriousness of problem behaviors. The five behavioral factors were 1) the severity or nature of the problem behavior, 2) the frequency with which the problem behavior occurs, 3) the duration over which the problem behavior has been occurring, 4) the generality of the problem behavior or the number of school environments the behavior occurs in , and 5) the percentage of the student's peers who engage in the same behavior. For each behavioral factor, three levels of that factor were determined: high, moderate, and low. Problem behavior descriptions were developed by the researcher, each of which presented the five behavioral factors at a predetermined combination of levels. Of 65 problem behavior descriptions, 3 3 described externalized problem behaviors and 32 described internalized problem behaviors. Subjects were asked to rate the seriousness of each problem behavior description on an 11 point scale, where l=mild and ll=severe. The results showed high levels of agreement among subjects on ratings of seriousness of problem behaviors. There was also high agreement between the subjects' ratings and ratings generated by the Class.BO expert system. Thus, Class. BD was validated. Further, the subjects gave highly similar ratings to descriptions of externalized and internalized problem behaviors. The results also indicated that the severity of the problem behaviors had the most impact on subjects' ratings. Subjects discriminated three levels of severity but only two levels of frequency, duration, generality, and percentage of peers. Finally, the results provided support for the use of analysis of variance as a viable method of knowledge engineering, i.e., extracting information about how experts make decisions. Its superiority over traditional interview methods is discussed.

Health care guidelines provide a means of assessing the best available research evidence on a given health care topic and offering recommendations about use of specific interventions and management of patient care. Guidelines allow clinicians, patients, health administrators and policy-makers to be efficiently informed and stay up to date on alternative care options. The development of guidelines is a complex and multidisciplinary process, with a defining feature of involving a panel of experts in steps such as selecting health care questions, assessing the research evidence, making judgements about health benefits and harms, and, ultimately, formulating recommendations. Guideline methodology has advanced over the past decades, including establishment of specific steps and standards to ensure trustworthiness of guidelines. However, there remain critical research questions on how to best accomplish and reach these standards, including how to best engage panels in the steps. This thesis presents a body of research on the development and evaluation of new methods for decision-making and considering health outcomes in guidelines, prioritizing health care questions for guidelines, and evaluating the guideline development process. It includes three studies: 1) a methodological study on developing health outcome descriptors to define health outcomes considered in decision-making by guideline panels; 2) a methodological study and randomized controlled trial to evaluate specific criteria for panels to consider when prioritizing health care questions for guidelines and to judge the importance of health outcomes; and 3) an instrument development and validation study to create a tool for panel members to evaluate the appropriateness of the guideline development process they participate in. In these studies, we established a method and steps for creating health outcome descriptors with panels, aimed at achieving consistency in how health outcomes are considered throughout the guideline development process, from prioritization to formulating a recommendation on the basis of those outcomes. The structured approach and criteria evaluated for prioritization of healthcare questions informed panel deliberations and decisions about choosing questions for their guideline topics, and the proposed methods for outcome prioritization facilitated panels in informing what the critical and important outcomes were for decision-making. Finally, the instrument we developed facilitated members of guideline panels to provide their assessment of the guideline development process and identify strengths and weaknesses and areas for improvement. Our findings will allow organizations responsible for guideline development to apply the new methods with their panels and to evaluate their guideline processes to inform quality-improvement efforts. / Thesis / Doctor of Philosophy (PhD) / Health care guidelines, also referred to as clinical practice or public health guidelines, involve summarizing the available research evidence on a given health care topic and issuing recommendations about the best care. Guidelines allow clinicians, patients, health administrators and policy-makers to be efficiently informed and stay up to date on alternative care options, such as the best current treatments and strategies to diagnose various diseases and health conditions. Developing a guideline is a complex and multidisciplinary process that includes involving a panel of experts, typically consisting of clinicians, patients, public health professionals and other providers or consumers of health care. The panel is involved in selecting the health care questions to address (e.g. specific treatments or diagnostic strategies to evaluate), reviewing a summary of the evidence from research studies, and making judgements about benefits and harms of alternate options or strategies. The panel then formulates recommendations that give guidance on what the best options are to use for the health condition in question. The steps and approaches to develop a guideline that is considered trustworthy have been established over the past decades, including universally accepted standards. However, there remain critical research questions on how to best reach these standards, including how to best engage guideline panels in the steps. The research work presented in this thesis focuses on proposing and evaluating new methods and approaches for guidelines panels to make decisions about health outcomes, priority health care questions for guidelines, and to evaluate the guideline development process. It includes three studies: 1) a study on creating health outcome descriptors with panels to provide a commonly accepted definition of a health outcome; 2) a study to evaluate specific criteria that panels can use to prioritize health care questions, and an approach to judge the importance of health outcomes; and 3) a study to develop a survey instrument for guideline panel members to evaluate the guideline development process they participate in. In these studies, we established an approach for creating the health outcome descriptors with panels, which helped in keeping consistency with how panels understood and considered different health outcomes throughout the guideline development process. The criteria evaluated for prioritizing healthcare questions informed panel discussions and selection of questions for their guideline topics. The proposed approach for judging the importance of health outcomes helped panels to select what the critical outcomes were for making decisions about the benefits and harms of alternate options or strategies. Finally, the survey tool we created allowed members of guideline panels to provide feedback on strengths and weaknesses and areas for improvement in the process after they participated in developing a guideline. Our findings will allow organizations responsible for guideline development to apply the new methods with their panels and to evaluate their guideline processes to inform quality-improvement efforts.

Failure to rescue (FTR) outcomes may be one consequence of the relationship be-tween healthcare provider behaviors and attitudes, organizational factors, and environ-mental factors that intersect to potentially threaten patient safety. Early warning systems (EWS) were designed as surveillance systems to reduce failure to rescue events and avoid morbidity and mortality. Challenges with EWS include lack of standardization, organiza-tional barriers, such as culture and supports, and human factor attributes such as intuition, expertise, and experience. The experience and perceptions of nurses using EWS technolo-gy as it relates to their clinical assessment, critical thinking, and decision-making skills has yet to be undertaken. This study adds to the body of EWS and FTR literature and the broader culture of safety literature in acute care environments. The purposes of this exploratory qualitative descriptive study was to explore the experiences of nurses using EWS in acute care practice settings and how they perceive it impacts on their critical thinking and clinical decision-making processes. The study identi-fied three informative findings: a) EWS has added value particularly with novice nurses or nurses new to practice settings, b) EWS provides benefits to nurses working in acute clinical environments that experience high volumes and high acuity of patients by alerting or reminding them about potential FTR situations, and c) Existing EWS may require mod-ification to improve adequacy, reduce redundancy, and reduce alarm fatigue. Based on the evidence reviewed, a qualitative study to increase our understanding of the experi-ence of nurses and their perception of the impact of EWS and related technology on their critical thinking and other nursing practice processes has the potential to contribute to a wider evaluation of EWS systems and to improve patient outcomes. / Thesis / Master of Science (MSc) / Before patients on general medical or surgical hospital units become so ill that they need to be transferred to an intensive care unit, they have abnormal vital signs and other physiological changes that can go unnoticed for 2448 hours. As these changes can be hard to detect and serious illness can begin very slowly at first, early warning systems have been developed to help health care professionals respond to patient’s conditions before they need to be in an intensive care unit. These early warning systems can be in the form of new technology and assist nurses with preventing a serious illness from becoming critical. It is not well research or understood how nurses experience such early warning systems technology and it is not well understood how nurses think this technology impacts their nursing practice. The overall aim of the study is to learn more about the experience and perception of nurses who use this technology, how they believe it informs their nursing practice and how it supports them in making clinical decisions about patient care.

Background: Preliminary evidence suggests there are differences in how older people and younger people with posttraumatic stress disorder (PTSD) present. However, currently little robust evidence exists relating to the presentation, assessment and intervention of PTSD in a rapidly ageing population. Faced with limited and conflicting evidence, clinical psychologists are reliant on their clinical expertise to make decisions in this context. Method: Eight studies reporting current prevalence of PTSD in older people were systematically reviewed. Semi-structured interviews with eight clinical psychologists with experience of assessment and intervention of post-traumatic stress symptomology in older people were analysed according to grounded theory methods. The analysis abstracted categories of data to construct a substantive theory of clinical decision making in this context. Results: Current and 12 month prevalence of PTSD ranged from 0.7% to 4.0% and 0.2% to 0.4% respectively. Partial PTSD was estimated at 1% to 10%. The quality of evidence limits the generalisability of the results. ‘Balancing complexity, resources and demand’ emerged from participants’ accounts as the core theoretical category, underpinning decision making in this context. Seven sub-categories comprise the model, ‘culture’; ‘NHS’; ‘clinician competencies’; “what the client brings”; ‘reconciling understanding’; ‘tailoring’ and ‘therapeutic relationship’. Conclusions: PTSD appears to be relatively rare among older people but more research is required to better understand the presentation and prevalence of full and partial PTSD. The theoretical model is broadly consistent with extant literature pertaining to the adaptation of psychological therapy for older people, offering further detail on implementation and the influence of treatment non-specific factors.

Information technology is ubiquitous in society and industry; however, healthcare is just beginning to explore how health information technology (HIT) can be optimized to support quality care. HIT can assist with standardizing care delivery, increasing access to evidence-based medicine, improving accuracy and ease of documentation, and assisting with patient education. Advanced Practice Registered Nurses (APRNs), specifically nurse practitioners (NPs) and certified nurse midwives (CNMs), play a pivotal role in the healthcare delivery system. To be effective practitioners, providers must manage, integrate, and assimilate a multitude of knowledge with each patient encounter. HIT can serve as the channel through which the NP and CNM provides cost-effective, efficient, and quality care. However, healthcare providers have been slow to adopt and implement HIT resources. We know that adoption of HIT by healthcare providers is varied among provider and practice settings. However, few studies have examined the impact on and utilization of information technology by APRNs, specifically nurse practitioners and certified nurse midwives.The purpose of this research was to investigate the utilization and influence of HIT on the clinical decision making of Kentucky nurse practitioners and nurse midwives (Kentucky APRNs). A descriptive cross-sectional design using survey methodology and convenience sampling was employed. Participants were asked to complete an author-modified, web-based survey tool that was based on current research. The 40-question tool was designed to explore providers' attitudes and perceptions of technology, determine their knowledge and utilization of various electronic and traditional print medical resources, and assess the penetration of and daily usage of HIT in practice.This study revealed information related to Kentucky APRN's utilization and influence of HIT on clinical decision making. Establishing exploratory Kentucky APRN findings will assist in evaluating further HIT utilization in Kentucky. Findings suggested that APRNs in Kentucky are beginning to explore the benefits of HIT; however, additional research will be required to identify the true penetration and utilization of technology in Kentucky. Although additional research is needed, HIT appears to be having an overall impact on the clinical practice of Kentucky APRNs.