This thesis focuses on the implementation of state-administered integration exams as part of the naturalization and settlement process in the United Kingdom and the Netherlands. Through analysis of key government documents and interviews with public servants and the experts involved, I argue that the actualization of the exam is a critical point in the policy process through which to understand how particular norms become embedded in not only the content, but the different requirements of each exam. In particular, I consider the role language-education experts, settlement experts, and the notable absence of migrants in the actualization of the exams under consideration. More importantly, I argue that while the state employs expert advice as a means through which to depoliticize the issue, the mechanisms through which this is done can in fact create spaces for the contestation of ideas. Drawing on the governmentality literature I argue that the British and Dutch borders are constructed and reified through the developing of test content, while also pointing to the ways in which non-state actors can mobilize their expertise to push for alternative, more open imaginings of the border. Through my comparison I also consider how integration has been framed as a problem with immigrants who do not have the right kind of orientation toward their ‘host’ community. The solutions to issues within immigrant communities (i.e. unemployment, poverty, poor health outcomes) rest in individuals moving from outsider to insider because these problems stem from the community’s position on the periphery of society. I argue that the immigrant’s affective orientation towards society becomes viewed as the source of these problems, and not the community's or society's orientation towards them. I then argue that the integration exam becomes a suitable solution because it solves multiple problems at once. The exam works as the mechanism through which desire is manufactured by making tangible the object of desire in the first place and by making society itself more exclusive. In this sense, the exam not only seeks to “ensure that those who desire ‘us’ are desirable to ‘us’” (Fortier, 2013, 3) by making immigrants prove themselves worthy, but also serves as a mechanism through which the state reasserts its authority over society. / Thesis / Doctor of Philosophy (PhD)

Title: Clinical Decision Making in Paramedicine Author(s) & affiliation(s): Michael Eby – McMaster University, Hamilton, ON, Canada Sandra Monteiro – McMaster University, Hamilton, ON, Canada Geoffrey Norman – McMaster University, Hamilton, ON, Canada Walter Tavares – McMaster University, Hamilton, ON, Canada Background: Paramedics are frequently required to make rapid decisions in an uncontrolled, dynamic environment, often with limited diagnostic information. In Ontario, paramedic practice is based on a set of provincial medical directives that provide diagnostic and treatment criteria. Unsupervised deviation from these directives is classified as a form of error and highly discouraged. To date, there is little known about how years of clinical experience or level of certification affect the way these medical directives are used. The purpose of this study was to examine the relationship between paramedic experience, training and accuracy of treatment decisions when faced with patients who meet and fall outside of the existing medical directives. Methods: Thirty-one participants (16 experienced / 15 novice) were recruited from two paramedic services in Ontario. “Experienced” was defined as in-practice for 5 years or more. Participants were presented with 9 scenarios; in 6 scenarios, the patient presentation fit within the existing directives, while in 3 scenarios, the patient presentation fell outside the medical directives. Multiple-choice responses were used to capture participants’ decisions to treat or not treat the patients. Responses were scored and submitted to a mixed-factorial ANOVA to evaluate differences in accuracy between case types, years of experience and level of training. Results: There was a significant effect of case type (p < 0.004). Accuracy was lower when the patient presentation did not meet the criteria of the medical directive (76.34% (CI = 67.15% to 85.53%) vs. 98.35% (CI = 96.55% to 100%) when they did. There was no effect of years of clinical practice or level of certification. Conclusion: The results suggest both novice and experienced paramedics are able to accurately apply medical directives, however, there is a significant decrease in accuracy when the patient presentation does not fit one. This variation in practice may have a significant impact on patient safety, and further research is required to determine what factors may be causing this decreased accuracy. / Thesis / Master of Science (MSc) / Paramedics work in a fast-paced, dynamic environment. The types of patients, and the situations paramedics encounter are different every day. Paramedic practice is based on a series of provincial medical directives that outline the different proceedures, medications and types of patients that can be treated. While these directives cover many of the cases paramedics encounter, there will always be cases that don’t “fit”. The purose of this study is to see if paramedics approach those types of cases in a different way, and if their years of experience or level of training change how good they are at idenfiying what patients require treatment. As there is very little paramedic specific research on this topic, this study will serve as a starting point for future research and hopefully stimulate discussion about paramedic practice, and how to support paramedics getting better at their jobs.

S'enlever la vie a longtemps été considéré comme un geste répréhensible pouvant faire l'objet de sanctions judiciaires, essentiellement si ce geste était commis de façon rationnelle. Sa dépénalisation, puis sa décriminalisation, s'accompagnent d'un changement de prise en charge qui consacre son caractère médical et pathologique. Se situant à la frontière entre symptôme pathologique et geste criminel, les raisons qui poussent les gens à s'enlever la vie font l'objet de vifs débats au 19e siècle, notamment dans le champ médical qui en vient à en formuler une explication consensuelle. Nous avançons que ce qui peut être compris comme un changement paradigmatique dans la compréhension médicale de ce geste, s'enlever la vie, est en fait le résultat d'un fractionnement conceptuel de cet objet. Une fois dépouillé de son caractère rationnel, le suicide émerge comme objet d'étude intrinsèquement pathologique. Toute rationalité associée à ce geste est subséquemment réinvestie dans d'autres objets notamment l'aide médicale à mourir et le suicide assisté. Le suicide et l'aide au suicide apparaissent ainsi comme deux façons, conceptuellement distinctes, de s'enlever la vie. Cette distinction entre ces deux entités comporte toutefois des ambiguïtés et s'articule dans un échafaudage empirique relevant moins de découvertes scientifiques médicales que de réflexions morales ou idéologiques. C'est à expliciter et à décrire les justifications empiriques du champ médical qui conduisent dans un premier temps à la formation d'un consensus sur la nature exclusivement pathologique des suicides et, dans un autre temps, à la reconnaissance de son caractère rationnel, que se consacre cette thèse. Pour ce faire, nous observons les justifications empiriques conduisant à la construction du suicide exclusivement pathologique en nous appuyant sur les articles scientifiques produits par les médecins de la fin du 19e siècle au début du 20e dans la revue l'Union médicale du Canada (UMC). Dans un second temps, nous portons encore notre attention sur la justification empirique des acteurs du champ médical ouvrant la voie à une décriminalisation de l'aide médical à mourir à la lumière des mémoires déposés par les professionnels de la santé dans le cadre de la Commission spéciale sur la question de mourir dans la dignité (2010-2011).

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Expert sport performance is developed by engaging in large volumes of high-quality training, particularly among endurance athletes, which must be supported by recovery. Despite the importance of recovery for sustaining and enhancing training, the concept has been largely absent from sport expertise research due in part to a lack of identified athlete-led recovery skills. Moreover, research on recovery has focused on a limited range of modalities, informed by practitioners' perspectives, at the expense of more complex, athlete-centered perspectives of what recovery may involve. The overarching purpose of this dissertation was to explore and describe the psychology of recovery in relation to sport expertise, and in doing so answer, "What might it mean for an endurance athlete to be skilled at recovery?". This purpose was addressed in four articles, organized in an exploratory, sequential, mixed-methods design. Expert sport performance is developed by engaging in large volumes of high-quality training, particularly among endurance athletes, which must be supported by recovery. Despite the importance of recovery for sustaining and enhancing training, the concept has been largely absent from sport expertise research due in part to a lack of identified athlete-led recovery skills. Moreover, research on recovery has focused on a limited range of modalities, informed by practitioners' perspectives, at the expense of more complex, athlete-centered perspectives of what recovery may involve. The overarching purpose of this dissertation was to explore and describe the psychology of recovery in relation to sport expertise, and in doing so answer, "What might it mean for an endurance athlete to be skilled at recovery?". This purpose was addressed in four articles, organized in an exploratory, sequential, mixed-methods design. Article 1 explored what recovery means to a sample of 13 elite endurance athletes with experience at multiple World Championships/Olympics. Each athlete participated in two semi- structured interviews, separated by an intervening week of keeping an activity journal of their recovery-related thoughts/actions. Using inductive reflexive thematic analysis, the findings portrayed recovery as encompassing a wide range of potential approaches that spanned multiple dimensions of feelings, levels of focus, and personal solutions. Further, the athletes assigned meaning to recovery in a particular time and context based on processes of 'defining short and long-term purposes', 'breaking and engaging', and 'negotiating and prioritizing'. These findings suggested that recovery is highly complex and individual, and that athletes define recovery according to personal and contextual conditions. Article 2 described the process of implementing recovery from the perspective of elite endurance athletes, using data from the same interviews as Article 1. Through inductive reflexive thematic analysis, I found that these athletes felt recovery was athlete-led: it involved processes of self-knowledge and planning (captured in the theme of 'Knowing my body'), self-awareness and interpretation ('Listening to my body'), and self-control and adjustment ('Respecting my body'), all connected in on-going development ('Learning my body'). During reflexive analysis, I further found that recovery self-regulation was integrated with people and places in the athletes' environments in ways that supplemented, facilitated, and provided for aspects of recovery. I integrated the athlete-led themes and environment-influenced themes in the Athlete Recovery Regulation Model, a heuristic model outlining how athletes shape their recovery using a set of athlete-led skills of recovery self-regulation. Article 3 aimed to describe how 22 elite cyclists and triathletes implemented certain recovery self-regulation skills between two key workouts, placed 2-3 days apart in their planned training. Using experience sampling methods, participants reported their momentary use of certain self-regulatory processes, as well as states of recovery and stress, up to eight times per day, leading up to and between the workouts. These processes were strongly correlated but differed in frequency, intensity, consistency, and predictors of use, which suggested that the processes represent synergistic yet unique competencies. Greater use of recovery self-regulation processes was associated with higher perceived stress and, to a lesser extent, lower perceived recovery, but there was no association with the time remaining to or elapsed after the key workouts. These findings indicated that elite endurance athletes self-regulate their recovery frequently and dynamically, largely in response to multidimensional feelings of stress. Article 4 refined the methods of Article 3 into a more controlled, representative task to assess and describe recovery between two key workouts. Using that task, planned analyses aimed to (a) describe the patterns of recovery self-regulation employed by 16 non-elite endurance athletes, and (b) assess those patterns in relation to the recovery of performance between successive workouts. Sixteen recreationally competitive cyclists participated remotely in two prescribed workouts, 48 hrs apart, on the Zwift virtual cycling platform. Between workouts, they participated in the same experience sampling design as Article 3. Findings showed that the non- elite cyclists also self-regulated their recovery frequently and dynamically. In contrast to the elite athletes in Article 3, this sample made greater use of self-regulatory processes specifically when experiencing physical stress, following the first workout, and use declined with time between the workouts. The recovery of performance in workout 2 relative to workout 1 was associated with more frequent use of certain self-regulatory processes, although overall, various characteristics of recovery self-regulation were not associated with performance recovery. These findings indicated that non-elite athletes engage in recovery self-regulation, albeit in potentially simpler and more reactive patterns compared to elite athletes. This dissertation makes several contributions. It proposes that an athlete's role in recovery may be conceptualized through athlete-led skills, as described in the Athlete Recovery Regulation Model. Further, it suggests that recovery may be understood in relation to various processes and perspectives of self-regulated learning. Methodologically, this dissertation advances a proof of concept that recovery can be examined in a traditional expertise paradigm, using experience sampling methods employed around a representative task in the context of inter-workout recovery. Finally, this dissertation advances an athlete-centered and skills-based understanding of recovery, which provides an alternative avenue for applied practitioners and sport organizations to address recovery with endurance athletes. Overall, this dissertation centers recovery on the athletes who engage in it by describing skills they can own and hone to shape their recovery.

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