This study utilises Tinto’s (1993) theoretical framework, known as the Model of Longitudinal Departure, to investigate success and failure in Foundation Year medical school in a Middle Eastern transnational location, through considering student background, cultural influence and academic transition. This case study is framed within a social constructivist epistemology utilising mixed methods, including quantitative pre-entry and academic attainment data, and qualitative student and staff interview data. Lack of contextual research combined with high failure rates, which negatively impact on students, institutions, sponsors and governments in this transnational first-year medical school experience, have led to the need to better understand the first-year medical school experience in this Bahraini context. The research questions investigate the student and staff perspectives of academic success and failure, together with the role of previous learning and the resulting implications for programme design. The research constructs a notion termed the ‘state of realisation’, this is the point at which students recognise and implement learning strategies associated with third level learning success. Additional findings include that English language competency measured by the IELTS and previous educational experience and achievement are pre-indicators of academic success. Within this transnational context culture is found to contextualize, frame and influence the students. Academic integration is found to be multi-faceted and complex, whereas social integration appears to be less challenging, seemingly facilitated by a strong culture of belonging. The research refines Tinto’s 1993 model into an appropriate framework for this transnational setting named the Model of Academic Success and Failure in a Transnational Context. It is within this framework that the constructed notion of the ‘state of realisation’ is situated. Findings on gender and academic success are unexpected, showing that males performed better than females in Foundation Year medical school in this transnational context. Further research is recommended to investigate this aspect in-depth.

The central aim of this thesis is to investigate how physicians, working for Pharmaceutical Product Development (PPD), a clinical research organisation (CRO), make decisions for a new industry standard for good clinical practice in medical device trials. This topic is introduced via review of decision theory and decision-making (DM) in contextual environments. Physician's career experiences, insights and perceptions of how they make regulatory compliance decisions, and how they think these new requirements should be met, are explored in the main study. The research rationale relates to the author's experience of physician DM in non-medical settings during 25 years working in the field, with a desire to ascertain how compliance influences are identified, assessed and synthesized into decisions within the workplace. Furthermore PPD physicians hold senior positions and new industry regulations require regulatory compliance decisions to be made at the highest level. In this study an interpretive phenomenological paradigm was used to ascertain how physicians make sense of industry regulation then make compliance decisions based on their roles, experiences, cues and sources of data available. Literature review identified 4 core themes (decision-making, errors, situation awareness and new requirements) that guided qualitative data collection via 2 mini-focus groups (n=3 per group) and semi-structured interviews (n=12). Review of 18 physicians' data occurred via framework analysis then comparing between contrasting positions presented. The findings found 4-5 dimensions under each core theme from which 2 frameworks were constructed: firstly, using DM tenets to guide physicians' DM in context and, secondly, identifying how to comply with new industry requirements. This research contributes to academia and practice via framework generation for DM in context. It is unique in its contextual exploration, analysis and interpretation of physicians' impressions, from departmental heads to company board members, in relation to their everyday working lives and the decision approaches used to ensure regulatory compliance within their organisational area of responsibility. The thesis ends by considering potential areas for further research such as deploying each framework, applying the framework concepts with other industry legislation changes or exploring alternative research paradigms in PPD.

This dissertation examines interaction in a hybrid educational and clinical medical context, specifically how students and tutors negotiate and display expertise and uncertainty in problem-based learning (PBL) tutorials in the final years of an undergraduate medical curriculum. I take a broad view of expertise and uncertainty, one which includes scientific knowledge, evidence-based explanations, warrants for uncertainty, personal experience and communicative performance. Taking a discourse analytic approach, I analyse what constitutes expertise in this tutorial setting and how it is negotiated and displayed through the participating students’ and tutors’ interactional dynamics. I examine the nature of the various tutorial activities, the educational and clinical context, and how factors associated with the ethos and approaches of both PBL and traditional clinical curricula influence the display and negotiation of expertise and uncertainty. The data were collected during 2008 in two teaching hospitals in Hong Kong. Participants were selected by convenience sampling. Eight tutorials were video or audio recorded, and the interactions were transcribed. The discourse analytical approach (activity analysis, Sarangi 2010a) is based on the notions of activity types (Levinson, 1992[1979]) and discourse types (Sarangi, 2000) as well as notions of participant structure, roles, frames, and alignment. The analysis is conducted in three stages. First, the structural mapping indicates that the tutorials were composed of three main elements – presenting a patient history, presenting clinical reasoning, and presentation of the findings of the physical examination and that these were recursive. Second, the interactional mapping shows that the dominant participants were the presenter of the patient history and the tutor, and that the main discursive device is questioning. Third, the thematic mapping shows that implicit throughout the interaction is the display of expertise through role performance, and the hybrid clinical and educational frames associated with these roles. Role, frame and activity characteristics interact to contribute to a complex setting within which participants could display degrees of expertise and uncertainty.

When I began the study, I was a full-time nurse educator. I taught student nurses at a hospital-based nursing school under the Hospital Authority. I also had a part-time job with the Open University of Hong Kong (OUHK) from 1998 to 2008, teaching subjects in the Bachelor of Nursing (NU305) program, Higher Nursing diploma courses (NU112C), and Master’s in Education (E804/E814) program. Currently, I am a nursing officer in an intensive care unit (ICU), responsible for training and quality assurance. As a former nurse educator in a hospital-based nursing school, a trainer, and a part-time tutor at OUHK, I was interested in learning more about the trends and changes related to the teaching and learning of adult learners. I observed that in many state policies and academic discussions, “lifelong learning” has replaced the term “adult education.” Indeed, interest in the idea of lifelong learning has recently grown (Smith 2002). Nonetheless, I did not clearly understand the idea of lifelong learning. and how it is different from adult education. There is also no universal definition of lifelong learning; rather, it is interpreted by various stakeholders in different ways (Kumar 2004). This aroused my interest in exploring the nature of lifelong learning, its implications to me as a tutor and a trainer, and the process by which empirical and qualitative data on lifelong learning can be collected.

L'estimation de la profondeur des veines sous-cutanées a été un sujet de recherche important ces dernières années en raison de son importance dans l'optimisation de pose de cathéters, de perfusions et plus généralement de ponctions veineuses. Par le passé, diverses techniques et systèmes de visualisation des veines ont été proposés, cependant le manque d'information sur la profondeur de la veine limite les possibilités pour une automatisation de la ponction veineuse ; le geste clinique restant dans de nombreux cas tributaire des compétences ou de l'expérience des cliniciens. Plusieurs techniques ont été proposées pour estimer la profondeur de la veine en utilisant la réflectance diffuse dont le principe repose sur la mesure de rapport de densité optique (ODR). Le concept de mesure de la profondeur des veines à l'aide de la technique ODR mérite d'être appliqué dans le monde réel en raison de son faible coût, de ses propriétés non invasives et du fait qu'il s'agit d'une technique de mesure sans contact avec la peau. Les travaux initiaux de Nishidate et. Al. [1] ont montré sur fantôme des résultats prometteurs. Cependant, une telle expérience peut ne pas être suffisante pour prouver son application pour la mesure in vivo en raison du manque d'expérience pour les données réelles. Par conséquent, ce travail de thèse a été commencé pour améliorer le modèle proposé par Nishidate et. Al. et l'élargir pour mesurer l'estimation in vivo de la profondeur de la veine sur de vrais patients. Le système proposé intègre de nouveaux composants tels qu'un algorithme de segmentation des veines, une méthode d'estimation plus précise du contenu en mélanine (Cm) et une conception matérielle entièrement nouvelle avec des composants stables. Les résultats obtenus par ODR ont été comparés à des données fournies par une machine Ultrason médicale. Les résultats de l'expérience montrent une corrélation de Pearson forte de 0,843 par rapport aux données échographiques et prouvent que le système développé est fiable pour la mesure in vivo de la profondeur de la veine. En outre, il est proposé d'utiliser un filtre de segmentation de veine optimal (filtre adapté) dans le système d'imagerie pour permettre une segmentation et par la suite une mesure de la profondeur automatique. / The estimation of subcutaneous vein depth has been an important research topic in recent years due to its importance in optimizing the intravenous (IV) access of venipuncture. Various techniques and system of vein visualization were proposed to improve the vein viewing, but the lack of vein depth information limits the system performance in assisting the IV access; thus, the IV access in many cases remains dependent on skill or experience of the clinicians. Several techniques were proposed to estimate the vein depth using diffuse reflectance of which the optical density ratio (ODR) technique is the most complete solution. The concept of measuring the veins depth using ODR based technique is deserved to be applied in the real-world due to its low cost, non-invasive properties and from the fact that it is a non-skin contact measurement technique. Nishidate et. al. [1] suggested an optimum conditions to measure the vein depth and thickness by using ODR which was supported by experiment with customized tissue-like agar gel phantom. However, such experiment may not be sufficient to prove its application for in vivo measurement due to the lack of experiment for real data. Therefore, this thesis work was first started to improve the proposed model by Nishidate et. al. and expand it to measure the in vivo estimation of vein depth on real patients. The proposed system incorporates new components such as an autonomous vein segmentation algorithm, a more accurate estimation method for melanin content (Cm) and a fully new hardware design with reliable parts. Importantly, the experiment estimate the vein depth on real patients as well as a through comparison with Ultrasound data. The experiment results show a strong Pearson correlation of 0.843 as compared to Ultrasound data and this evidence that the developed system is works for the in vivo measurement of vein depth. Besides that, an optimum vein filter (matched filter) is proposed to be used in the imaging system to preserve the most accurate vein detection and allow the system to produce the results with least detection error. The selection of the optimum vein filter has laid an important platform from which to obtain the accurate vein segmentation of a NIR image.

Although clinical reasoning is both broad and complex, the term “clinical reasoning” is contested and multiple definitions have been mooted within different contexts. In its simplest form, clinical reasoning is regarded as a “decision-making” process. Other definitions outline it in terms of a complex cognitive process, posited within multiple contextual factors. Traditionally, clinical reasoning models have been based upon cognitive theories. More recently, interpretive theories have been applied. Despite extensive research over the past four decades, no consensus on how clinical reasoning actually occurs has been achieved. Accurate clinical reasoning is vital to patient safety. Its importance as an essential clinical competence for healthcare professionals is well established. Indeed, it is the crux of a clinician’s work. Frequently, Foundation doctors are the first to review acutely unwell patients. During out-of-hours shifts senior help can be scant and Foundation doctors may have to rely on their own initial clinical reasoning to manage acutely unwell patients. This PhD explores clinical reasoning development in the transition phase between final year medical student and Foundation doctor (5MB-FY1 transition) in relation to acutely unwell patients. It follows a cohort of final year medical students from a single UK university on their clinical reasoning journeys as they transition into Foundation doctors, focusing on the role of the simulated healthcare setting and the workplace. The principle research question for this PhD was how does clinical reasoning develop across the transition phase between final year of medical school and Foundation year one? Within this overarching research question, the following sub-questions were posed: What do participants understand by the term clinical reasoning? What types of clinical reasoning experiences do participants narrate? How do participants clinically reason for acutely unwell patients? Which factors do participants perceive as being facilitating and hindering to their clinical reasoning? How do participants’ clinical reasoning processes develop across the 5MB-FY1 transition phase? This PhD uses multiple methodologies derived from interpretive approaches in innovative ways to tap into clinical reasoning processes and its development across four data collection points: T1: group and individual interviews; T2: Ward Simulation Exercise observations and stimulated recall interviews; T3: workplace observations and stimulated recall interviews; T4: final interviews. Data were collected from T1/T2 and T3/T4 during the final year of medical school and Foundation year one respectively. Primary thematic analyses were carried out cross-sectionally and longitudinally in terms of what participants said and how they said it. Secondary narrative analyses were undertaken of participants’ Personal Incident Narratives. By taking an interpretive approach, the complexities of clinical reasoning processes, both in terms of internal cognition and external socio-cultural influences were illuminated, drawing upon clinical reasoning, complexity and situated learning theories. The key findings of this PhD were that participants conceptualised clinical reasoning as a “decision-making” and “thinking” process, leading to a clinical judgement for patient care; participants narratives aided understanding of clinical reasoning process and factors which facilitated and hindered them; participants used experiential knowledge and protocols to clinically reason for diagnosis, investigation, management and prioritisation; participants retained flexibility and contextual variability in the processes of making their clinical judgements; multiple factors facilitated and hindered the equilibrium of clinical judgement processes; and clinical reasoning development is dependent upon a complex interplay of individual, interpersonal and systemic factors which are deeply embedded in social-cultural theory. This study has multiple strengths and original features such the high participant retention rate throughout the longitudinal study, the exploration of the 5MB-FY1 transition, contemporaneous observations of clinical interactions with patients, the exploration of the out-of-hour setting contemporaneously and the multiple methods of data collection used in innovative ways. This PhD develops the published literature further in these domains. However, its challenges were predominantly ethical, such as lack of patient capacity to consent in the workplace.

Ένα εκπαιδευτικό λογισμικό κατασκευάζεται, προκειμένου με τη χρήση του να εκπληρωθούν συγκεκριμένοι μαθησιακοί στόχοι. Μπορεί να χρησιμοποιηθεί ως συμπληρωματικό μέσο διδασκαλίας από τον εκπαιδευτή ή ως υποστηρικτικό μέσο αυτοδιδασκαλίας από τον εκπαιδευόμενο. Αποτελεί μέσο αξιολόγησης ή αυτοαξιολόγησης του εκπαιδευόμενου, χωρίς βέβαια αυτό να αποτελεί κύριο σκοπό για την κατασκευή του. Οι σύγχρονες τεχνολογίες εκπαιδευτικού λογισμικού, που βασίζονται στις τεχνολογίες δικτύων υπολογιστών και των συστημάτων υπερμέσων, προσφέρουν την δυνατότητα να εξηγούνται, με παραστατικό τρόπο και πολλαπλά μέσα παρουσίασης, τα γνωστικά αντικείμενα, να διευκολύνεται η επικοινωνία και η συνεργασία μεταξύ εκπαιδευόμενων και εκπαιδευτών, να καταργείται η αποκλειστική χρήση μιας πηγής μαθησιακού υλικού, η οποία πολλές φορές περιέχει ξεπερασμένες πληροφορίες και, ως συνεπακόλουθο όλων αυτών, να μπορεί να αναπτύσσεται η κριτική σκέψη του υποκειμένου στην εκπαίδευση. Στην εργασία αυτή παρουσιάζουμε την συμβολή ενός τέτοιου προηγμένου συστήματος στην δημιουργία ενός μαθήματος για την Ακτινοπροστασία στους χώρους Υγείας. Για το σκοπό αυτό χρησιμοποιήσαμε μια εκπαιδευτική πλατφόρμα ικανή να παρουσιάζει προσαρμοστικά το περιεχόμενο, να προτείνει μαθησιακές δραστηριότητες ανάλογα με τον εκπαιδευόμενο, να προσφέρει διαφορετικούς τρόπους επικοινωνίας και συνεργασίας ανάλογα με το επίπεδο και τη διάθεση του μαθητή. Περιγράφουμε τους λόγους για τους οποίους τέτοια συστήματα μπορούν να προσφέρουν στην Ιατρική εκπαίδευση, καθώς και το πόσο απαραίτητο είναι το μάθημα της ακτινοπροστασίας για τα επαγγέλματα Υγείας. Παραθέτουμε την λειτουργικότητα των εργαλείων, τα οποία έχουν στη διάθεση εκπαιδευτές και εκπαιδευόμενοι, και τέλος αναφέρουμε τις τροποποιήσεις που κάναμε προκειμένου το σύστημα να διαθέτει ένα προσαρμοστικό τρόπο αξιολόγησης. Δίνουμε τα αποτελέσματα μιας πρώιμης αξιολόγησης του συστήματος-μαθήματος, από φοιτητές της Νοσηλευτικής του Τεχνολογικού Ινστιτούτου της Πάτρας. Τέλος αναφέρουμε μια συνοπτική περιγραφή της αρχιτεκτονικής και του τρόπου υλοποίησης του συστήματος. Η παρούσα εργασία αποτελεί ένα πρότυπο τόσο του πώς μια εκπαιδευτική πλατφόρμα μπορεί να χρησιμοποιηθεί για εκπαίδευση στους χώρους Υγείας, όσο και του πώς μια προϋπάρχουσα τέτοια εκπαιδευτική πλατφόρμα μπορεί να βελτιωθεί χρησιμοποιώντας τεχνολογίες τεχνητής νοημοσύνης. / -

Cette thèse a pour objet la formation d’équipes de professionnels de santé aux situations d’urgence vitale. Notre travail se focalise sur des techniques innovantes de simulation pour des équipes interprofessionnelles, et notamment son cœur : le débriefing. Plusieurs travaux ont montré que des débriefings sans instructeur pouvaient être efficaces pour l’apprentissage individuel. Mais aucune étude n’avait exploré le débriefing en équipe sans instructeur pour l’amélioration de la performance d’équipe. Or la prise en charge d’un patient en situation d’urgence vitale est presque systématiquement du ressort d’une équipe. Grâce à l’association de méthodologies de recherche quantitative et qualitative, nous avons évalué l’efficacité et analysé le contenu de l’auto-débriefing en équipe sans instructeur pour améliorer la performance de prise en charge d’urgences vitales par des équipes interprofessionnelles. Ce travail permet d’optimiser la formation des instructeurs et de faciliter la diffusion des formations interprofessionnelles par simulation. / This thesis aims at training healthcare teams in life-threatening emergency situations. Our work focuses on innovative simulation techniques for interprofessional teams, and especially its heart: the debriefing. Several studies have shown that debriefing without instructor could be effective for individual learning. But no study has yet explored team debriefing without instructor as a possible approach to improving team performance. However patient care in emergency life-threatening situations is almost always the responsibility of a team. Combining quantitative and qualitative research methodologies, we evaluated the effectiveness and analyzed the content of within-team debriefing without instructor to improve performance of life-threatening emergencies management by interprofessional teams. This work optimizes instructor training, and facilitates diffusion of simulation-based interprofessional training.

Dans le contexte français des formations en soins infirmiers, cette thèse propose de concevoir le soin comme un processus de médiation et d’échange de significations entre les acteurs concernés, notamment soignés et soignants. Les processus communicationnels identifiés ici mettent en jeu des valeurs, des représentations et des positionnements identitaires qui concourent à l’élaboration et à l’expression d’une professionnalité soignante. Le corpus de cette recherche est organisé à partir d’images médiatiques, d’activités de soin, de récits relatifs à des situations professionnelles, d’un récit de vie et d’une monographie. Ces cinq sources de données permettent une approche compréhensive des formes communicationnelles mobilisées dans le contexte du soin, des effets de sens relatifs aux pratiques observées ainsi que des logiques d’intervention et de relation des personnels soignants. Le concept de corps-monde est proposé comme modèle intégrateur des rencontres et des distances relationnelles co-construites par les acteurs du soin. Enfin, pour répondre aux questionnements d’ordre stratégique auxquels se trouvent confrontées les organisations de santé dans le cadre des nouvelles pratiques de soin et des évolutions de la formation infirmière, la notion centrale de soin-communicant est installée afin de définir le soin comme un système complexe d’échanges signifiants. Ce concept tente de formaliser les espaces de médiation propres à la construction d’une professionnalité soignante pertinente et cohérente au regard des nouveaux enjeux de la formation en soins infirmiers. / In the french context of nursing care teaching, this thesis aims at conceiving nursing as a process of mediation and communication notably between especially patients and care givers. The identified communication process involving values, self-identification and representation help to build up and express the caring professionalism. The background documents are organized from 5 types of data which are media focuses, caring acts, professional situation reports, life stories and monographs. These data allow the comprehension of the communication items which are used in the health care context, also the effects of the observed practice meanings and finally the care giver way of acting and relating. The carers build medical encounter and distance relationships. This is presented as the “world-body” concept. As part of the new care exercises and the nurse teaching evolution, the health care organizations are faced with strategic questionings. In order to answer those interrogations, the central concept of “communicating-care” is developed. This leads to define the care act as a meaningful and complex interaction system. This concept tries to formalize mediation areas which are specific to the building of a relevant and coherent caring professionalism as regards with looking at the new challenges in nurse care teaching.

Le développement rapide des nouvelles technologies numériques est en passe de révolutionner l’enseignement classique de l’odontologie comme dans de nombreuses spécialités médicales. En effet, l’avènement de nouveaux dispositifs alliant réalité virtuelle et dispositif haptique permettant de simuler au plus juste les gestes techniques de l’odontologie, laisse entrevoir la possibilité d’évaluer plus objectivement les compétences des futurs Chirurgiens-Dentistes et de renforcer la formation traditionnelle. Au travers de différentes expérimentations pédagogiques dans les domaines de l’implantologie, de la dentisterie restauratrice et de la chirurgie orale, nous avons voulu : (i) évaluer l’impact de la simulation haptique sur la formation en odontologie en nous focalisant sur l’implantologie et la dentisterie restauratrice ; (ii) définir de nouveaux paramètres pédagogiques pour essayer de les évaluer objectivement et estimer l’importance de la vision 3D en simulation / The rapid development of new digital technologies is revolutionizing the classical teaching of dentistry as in many medical specialties. Indeed, the advent of new devices combining virtual reality with a haptic device allowing to simulate the technical gestures of odontology, suggests the possibility to evaluate the skills of future Dentists more objectively and to strengthen traditional training. Through various educational experiments in the fields of implantology, restorative dentistry and oral surgery, we wanted to: (i) assess the impact of haptic simulation on odontology training by focusing on implantology and restorative dentistry ; (ii) define new objectively evaluable pedagogical parameters and to estimate the importance of 3D vision in simulation