Although older Canadians constitute a large portion of patients in hospital, many receive less-than-optimal drug care. Most registered nurses (RNs) and other health care professionals who provide older adults (OAs) with drug therapy lack pre-professional education about that practice. Concurrently, there is little research available about how RNs learn about drug therapy for OAs. Using a qualitative method, this thesis explores hospital RNs’ insights about their knowledge about drug therapy for OAs, their associated learning needs and strategies, and contextual influences on their learning. The findings illuminated RNs’ extensive knowledge, their learning needs and varied learning strategies, and constraints and facilitators of their learning. Drug therapy for OAs is a complex activity. RNs play a pivotal role in that care and have ample knowledge. RNs’ learning is holistic, ongoing, mostly informal, and reflective of many adult-learning theories. By learning, RNs build and transform their repertoires of knowledge to stay current with the quickly changing landscapes of health care, gerontological know-how, and drugs and drug practices. As a result, sometimes RNs protect not only OAs but also other hospital stakeholders from the negative effects of uninformed practice. Nurse educators should teach students about drug therapy for OAs and broaden their own views about RNs’ knowledge and learning strategies for that care. Nurse leaders should maximize chances for RNs to learn and prepare them to influence other stakeholders in ways that support learning. Hospital administrators and other stakeholders should recognize RNs’ pivotal role in drug care and support their learning through organizational changes. Communities should design strategies that ease RNs’ learning. Policymakers should replace corporatism with innovations that champion learning. Researchers and RNs should collaborate on novel projects that bolster RNs’ learning.

Introduction: Facial lipoatrophy is a stigmatizing hallmark for HIV-positive status, and can lead to poor social functioning. Information gleaned from an economic evaluation of facial lipoatrophy treatments would inform policy decision making concerning potential public insurance coverage. Methods: A decision-analytic model was used to estimate the lifetime costs and Quality Adjusted Life Years (QALYs) gained from treatments using either poly-l-lactic or and polyalkylimide gel for HIV positive patients. Disease progression probabilities and utilities were derived from the literature. Costs were obtained from interviews with physicians and product distributors. Findings: Incremental costs per QALY were $66,409 CAD/$57,352 CAD for poly-l-lactic acid, and $48,715 CAD/$45,457 CAD for polyalkylimide gel® (Societal perspective/Ministry of Health perspective). Sensitivity analysis did not have a significant effect on the lower incremental costs per QALY reported for polyalkylimide gel. Conclusion: Our base-case analysis revealed that treatments using polyalkylimide gel offers lower ICUR than treatments using poly-l-lactic acid.

Introduction: Facial lipoatrophy is a stigmatizing hallmark for HIV-positive status, and can lead to poor social functioning. Information gleaned from an economic evaluation of facial lipoatrophy treatments would inform policy decision making concerning potential public insurance coverage. Methods: A decision-analytic model was used to estimate the lifetime costs and Quality Adjusted Life Years (QALYs) gained from treatments using either poly-l-lactic or and polyalkylimide gel for HIV positive patients. Disease progression probabilities and utilities were derived from the literature. Costs were obtained from interviews with physicians and product distributors. Findings: Incremental costs per QALY were $66,409 CAD/$57,352 CAD for poly-l-lactic acid, and $48,715 CAD/$45,457 CAD for polyalkylimide gel® (Societal perspective/Ministry of Health perspective). Sensitivity analysis did not have a significant effect on the lower incremental costs per QALY reported for polyalkylimide gel. Conclusion: Our base-case analysis revealed that treatments using polyalkylimide gel offers lower ICUR than treatments using poly-l-lactic acid.

Doctor of Philosophy / Department of Educational Leadership / Sarah Jane Fishback / This bounded case study explored ten purposefully selected physician participants’ perceptions of the effectiveness of an eight session, two year in-house physician leadership development program at a major Academic Medical Center (AMC) in the Midwest. While physicians are generally educated to care for patients in their specialty area, reforms necessitate the need for physician leadership involvement in metric tracking by healthcare organizations in order to provide a focus on quality patient care and safety. Participants indicated finding the course effective, especially the negotiations and finance modules. These modules provided new language, a better understanding of processes and an opportunity to develop skills through interactive class exercises such as case studies. Participants described an increased self-awareness of their interpersonal skills and expressed a desire for greater exposure to emotional intelligence principles. Participants experienced a transformational shift in how they constructed their identity as a physicians and leaders, and questioned assumptions about the physician’s role in healthcare. While effective in initiating a process of exploration, this course was not sufficient to meet the goals and objectives of the program. Therefore, recommendations for the advanced course included a focus on leadership competencies identified by Dye and Garman (2006) as cited by Dye and Sokolov (2013), emotional intelligence, and transformational leadership.

Doctor of Philosophy / Department of Family Studies and Human Services / Karen S. Myers-Bowman / This qualitative research study was conducted in order to understand more about the phenomenon of adolescent cigarette smoking and to contribute to the body of knowledge on youth substance abuse prevention. The exploratory study incorporated the personality types associated with True Colors, Inc. (2008), as a tool to use when gathering information from non-smoking adolescents and parents. Adolescent-parent dyads were interviewed about how personality characteristics influenced several factors regarding the adolescents’ choice to not smoke cigarettes. The participants indicated that they were comfortable with the True Colors model for identifying their personality types. Furthermore, the participants tended to provide information that reflected their personality. The “gold” personalities exhibited a strong sense of right and wrong, and it was important for them to be responsible, follow rules and respect authority. The adolescents identified as having “orange” personalities tended to put themselves at the center of conversations and reported that they made many of their own decisions. They were also spontaneous and witty. Personalities that were “blue” types demonstrated the most compassion and empathy. They valued relationships and they did not want to disappoint others when making decisions. The fourth color was the “green” personality. These individuals were visionaries, and were analytical and logical with their responses. They valued knowledge and were apt to get their information from books and television when making decisions. Implications for research include that, rather than studying why adolescents do smoke cigarettes, it may be wise to also study why adolescents choose to not smoke cigarettes in order to more fully understand the phenomenon. The study also provided implications for practitioners regarding adolescent cigarette smoking prevention programs. Because the current study found differences in how the personality types of adolescents received information, youth prevention programs should utilize a variety of strategies to address the unique differences in adolescent personalities in order to be most effective.

Context: The study of expertise in medical education has tended to follow the traditions of describing either the analytic processes or the non-analytic resources that experts acquire with experience. We argue that a critical function of expertise is the ability to transition from the automatic mode to the more effortful mode when required – a transition referred to as ‘slowing down when you should’. Objectives: To explore the phenomenon of ‘slowing down when you should’ in operative surgical practice and its role in intra-operative surgical judgment, and to develop conceptual models of the factors involved in the display of this transition in surgical operative practice. Design: In Phase 1A, 28 surgeons were interviewed about their views of surgical judgment in general and their perceptions of the role of this phenomenon in operative judgment. In Phase 1B, a subset of surgeons from Phase 1A was re-interviewed to explore their perceptions of automaticity in operative practice. In Phase 2, observational sessions (and brief interviews) were conducted of surgeons in the operating room to explore the nature of this phenomenon in its natural environment. Results: The surgeons in this study recognized the phenomenon of ‘slowing down’ in their operative practice and acknowledged its link to surgical judgment. Two main initiators were described and observed: proactively planned ‘slowing down’ moments occurring intra-operatively initiated by critical events anticipated pre-operatively and situationally responsive ‘slowing down’ moments initiated by emergent cues intra-operatively. Numerous influences of this transition were uncovered. A control dynamic emerged as surgeon’s negotiated ‘slowing down’ moments through trainees in their supervisory academic practice. Numerous manifestations of this phenomenon were observed in the operating room and considered using a cognitive psychology attention capacity model. Conclusions: This study offers a conceptual framework for understanding the role of ‘slowing down when you should’ in operative surgical practice, providing a vocabulary that will allow more explicit consideration of what contributes to surgical expertise. Consideration of this framework with its consequent ability to make surgical practices more explicit has implications for self-regulation in practice, surgical error, and surgical training.

Continuing medical education has been characterized as didactic and ineffective. This thesis explores the use of Knowledge Building theory, pedagogy, and technology to test an alternative model for physician engagement—one that emphasizes sustained and creative work with ideas. Several important conceptual changes in continuing medical education are implied by the Knowledge Building model—changes that extend the traditional approach through engagement in (a) collective responsibility for group achievements rather than exclusive focus on individual advancement and (b) work in design-mode, with ideas treated as objects of creation and assemblage into larger wholes and new applications, with extension beyond belief-mode where evidence-based acceptance or rejection of beliefs dominates. The goal is to engage physicians in “cultures of participation” where individual learning and collective knowledge invention or metadesign advance in parallel. This study was conducted in a continuing medical education End-of-Life Care Distance Education course, for family physicians, from 2004 to 2009. A mixed methods case study methodology was used to determine if social-mediated Knowledge Building improved physicians’ knowledge, and if so, what social network structural relationships and sociocognitive dynamics support knowledge improvement, democratization of knowledge, and a metadesign perspective. Traditional pre-/posttest learning measures across 4-years showed significant gains (9% on paired t-test = 5.34, p < 0.001) and large effect size (0.82). Social network analysis of ten 2008/2009 modules showed significant difference in density of build-on notes across groups. Additional results demonstrated a relationship between high knowledge gains and social network measures of centrality/distribution and cohesion. Correlation of posttest scores with centrality variables were all positive. Position/power analyses highlighted core-periphery sociocognitive dynamics between the facilitator and students. Facilitators most often evoked partner/expert relationships. Questions rather than statements dominated the discourse; discourse complexity was elaborated/compiled as opposed to reduced/dispersed. Themes beyond predefined learning objectives emerged and Knowledge Building principles of community responsibility, idea improvability, and democratization of knowledge were evident. Overall, results demonstrate the potential of collective Knowledge Building and design-mode work in continuing medical education, with individual learning representing an important by-product. There were no discernible decrements in performance, suggesting significant advantages rather than tradeoffs from engagement in Knowledge Building.

Cardiovascular disease (CVD) is the leading cause of death among Canadian women, and accounts for up to 30% of deaths among women worldwide. Women with CVD are typically older than their male counterparts, experience worse functional status, are more likely to experience non-CVD health conditions such as diabetes or arthritis, and will live with these health conditions for more years than men. Physical activity (PA) and cardiac rehabilitation (CR) participation is lower among women compared to men, but little is known about the PA and health promotion experiences, priorities and practices of older women living with CVD. Guided by a socioenvironmental approach to health promotion, a mixed method design involving a mail survey (N=127) and qualitative interviews (N=15) was employed to describe and explore the PA and health promotion practices, preferences and priorities of older women (≥65 years) living with CVD in the Champlain health region of Ontario. Nearly 60% of survey respondents were referred to CR. Logistic regression analysis revealed urban residence as a predictor of CR referral (p<0.01, OR=3.24; 95% CI: 1.44-7.30). Nearly 55% of respondents attended CR, which was predicted by CR referral (p<0.01, OR=32.26; 95% CI: 9.26-111.11), availability of transportation (p<0.05, OR=9.96; 95% CI: 1.22-81.41), and a history of structured PA (p<0.05, OR=3.64; 95% CI: 1.16-11.36). Respondents were more active than their peers, but received little support from their physician for PA. Older women’s incidental PA (walking six or more hours/week for transportation) was predicted by their sense of community belonging (p<0.05, OR=2.6; 95% CI: 1.05-6.29) and having energy for PA (p<0.05, OR=5.8; 95% CI: 1.21-27.92). Interview participants (including four who had attended CR) described health as a resource that enables them to lead busy, active lives. Most participants attributed CVD to genetics or stress, but still engaged in health-promoting activities, including structured and incidental PA. Participants engaged in ‘incidental’ activities such as walking, gardening, and housekeeping tasks purposefully, with the intention of maintaining or improving their health. This research can inform public health initiatives and health care services (including CR) to better meet the needs and preferences of the growing population of older women with CVD.

This thesis seeks to evaluate the International Pediatric Emergency Medicine Elective (IPEME) as a case study of a peace-through-health initiative. Using the reasoning of Scolnik (2006), IPEME is first evaluated in terms of narrow, short-term outcomes and subsequently considered in terms of the greater body of peace-through-health work. A novel evaluation tool was designed to examine change in students’ ethical and professional attitudes over the course of the four-week elective. Supplementary qualitative data was collected to shed light on evaluation findings and provide insight into the advantages and disadvantages of the IPEME curriculum. Ethics and professionalism were defined in terms of the WHO 5 Star Global Criteria for Global Doctors conceptualized by the World Health Organization (Boelen, 1996). This research discusses these findings in light of the study’s limitations and considers their implications for IPEME as a medical elective and for its contribution to the greater body of peace-through-health work.

The world’s understanding of HIV/AIDS is grounded in biomedicine and shaped by cognitive psychology. Both biomedicine and cognitive psychology bonded with historically top-down development mechanisms to create ‘prevention’ strategies that obscured from vision the root causes of the pandemic. Within this hierarchy, bio-medicine and the cognitive psychological conception of human beings silenced indigenous voices and experiences of communities fighting HIV/AIDS. This is most certainly true in the case of Sub-Saharan Africa. This research explores the emergence of the Community Capacity Enhancement – Community Conversations prevention approach that places community dialogue, and the voices of communities, at the forefront of the battle to end HIV/AIDS and deconstruct and challenge the forms of structural violence that hold prevalence rates in their place. Within these spaces, oral traditions, indigenous knowledge, and resistance illustrate new and complex pictures of the viruses’ socio-economic impact and provide new foundations for community generated movements to curb the virus.