This qualitative exploratory case study focused on how nursing staff perceived a complex transformational change within a large tertiary care teaching hospital. In an effort to improve the understanding of transformational learning and change, this study examined a change that required nursing staff to critically reflect on their practice and if necessary change their values, beliefs and attitudes. The objectives of the transformational innovation were to increase professional accountability and authority by changing the decision-making of nursing staff to a more autonomous process. The structural changes introduced included implementation of unit councils and primary nursing. Study data consisted of documentation collected over a three and a half year period during the implementation of the transformational change. During the analysis, similar phrases were coded and categorized and then re-categorized into major patterns or ideas reflecting perceptions of the innovation, transformational learning process, and outcomes of the change. Results describe the concerns, learning needs, and system considerations that influenced staff when implementing a transformational change. The results of this study will be of interest to administrators and educators as they prepare staff for future challenges.

Comment peut-on enrichir le travail des infirmieres et promouvoir la satisfaction au travail? A l'hopital general d'Ottawa, le comite sur la documentation de la demarche de soins a developpe un outil de documentation qui combine la phase de la cueillette des donnees, des diagnostics infirmiers et la phase intervention. Nous utilisons le cadre theorique le plus disponible et le plus connu dans la mesure de l'effet d'une restructuration des taches: le modele des dimensions des taches d'Hackman & Oldham (1980). L'hypothese de cette recherche est qu'il existe des differences significatives entre le groupe experimental qui utilise le nouveau plan de soins du patient, considere comme un enrichissement de la tache de l'infirmiere, et le groupe controle utilisant l'ancien plan de soins. Cette difference significative est mesurable par le biais du pointage de motivation potentielle, des dimensions principales de la tache, des etats psychologiques et des resultats en fonction du travail de l'infirmiere qui sont mesures en periode pre et post-test. On observe pour le gyoupe controle une baisse significative de la moyenne du pointage de motivation potentielle entre la periode pre et post-test alors que le groupe experimental exprime une tendance a la hausse. Les facteurs extrinseques agissent negativement sur la motivation et la satisfaction des groupes controle et experimental. Par contre, il semble que l'activite d'enrichissement d'une partie de la tache de l'infirmiere ait permis de prevenir une baisse de motivation dans le groupe experimental. En general, l'implication theorique la plus importante de ces differentes analyses est qu'il existe des interactions entre la demarche de soins et le pointage de motivation potentielle. Les resultats nous procurent une certaine evidence en faveur de la restructuration des taches. Les changements qu'on apporte a la structure du travail peuvent conduire a des reactions favorables face aux taches. (Abstract shortened by UMI.)

An important aspect of the prevention and possible elimination of tuberculosis (TB) in Canada relates to the screening practices of primary care physicians. There is good evidence that screening for TB is under-utilized by physicians in Canada and other industrialized countries. This thesis was conducted to determine: (1) family physicians' knowledge and beliefs about the prevention of tuberculosis, (2) their awareness and use of TB screening guidelines circulated by the Ottawa-Carleton Health Department, (3) the perceived barriers to screening and, (4) to identify factors associated with primary care physicians knowledge and beliefs about the prevention of tuberculosis. Predictor variables included gender, year of graduation, certification, practice setting, whether a physician lived in a developing country, whether a physician practiced medicine in a developing country and the percentage of persons from developing countries in physicians' practices. Family physicians had a moderate level of knowledge about the prevention of tuberculosis which varied according to the specific components of screening. Younger physicians and practitioners with a higher proportion of clients from developing countries were more knowledgeable about screening for tuberculosis. Only 13% of the total variability in physicians' knowledge however, was explained by the regression model containing these two explanatory variables. Physicians' self-efficacy beliefs also varied according to specific aspects of screening. Self-confidence about prescribing INH and managing INH therapy was low. Only 48% of the sample believed that patient compliance with INH therapy was good. With respect to barriers to screening, 60% of physicians felt that reimbursement for TB screening was inadequate, 30% cited language/cultural problems with clients, 90% felt that more continuing medical education (CME) programs were needed and 65% were in favor of a central TB screening clinic. Awareness of tuberculosis prevention and treatment guidelines circulated by the Ottawa-Carleton Health Department was low. (Abstract shortened by UMI.)

Assessment practice in Health Professionals Education (HPE) has serious consequences for the student and public as it impacts on student learning and outcomes, ultimately certifying a graduate as safe for public practice, and thereby affecting patient care. The goal is for assessment to be practiced in such a way as to drive student learning and outcomes in a desirable manner using assessment to help contribute to the creation of powerful learning environments. Critically, this may not take place without the assessor. In resource-constrained, Southern contexts, the individual lecturer is usually responsible for practicing assessment, as opposed to a collective assessment committee. It is crucially important to explore how lecturers practice assessment and if their practice positively drives learning. Although lecturers are the key role players in assessment practice in the South, little is known of lecturer HPE assessment practice in the global South. Additionally, these lecturers in HPE generally have no or little formal training in assessment. There is a need for evidencebased, theory-informed, valid and appropriate interventions for faculty training and continued professional development that target lecturer assessment practice. I propose that lecturer assessment practice is a behaviour, and that how lecturers' think of assessment (their underlying understanding or conceptions, including assessment literacy) and interacting factors (personal and contextual influences), shape their assessment behaviour. In order to explore this behaviour, the conceptual frameworks of Health Behaviour Theory (HBT) and Southern Theory were employed as theoretical underpinnings guide this research study into lecturer assessment practice in the global South. To this end, using purposive and maximum variant sampling, lecturers in diverse Southern contexts were interviewed (South Africa and Mexico) and lecturers' conceptions of assessment and factors influencing their assessment practice were identified and described in a Phenomenographic outcome space and novel HBT-derived model of lecturer assessment practice respectively. The findings from this study, while needing to undergo further validation in additional Southern contexts, may assist in guiding the design and implementation of strategic and targeted faculty assessment training interventions to enhance lecturer assessment practice leading to the creation of powerful learning environments, thereby improving student outcomes and ultimately improving patient care.

Teamwork has become an important goal of contemporary healthcare. Therefore, one of the objectives of educating health professionals is to impart teamwork skills. While teamwork skills have become widely acknowledged as important for health sciences education (HSE), teamwork pedagogy within the ambit of interprofessional education within HSE is contested in the literature. The need to trouble the meaning of concepts within the interprofessional field to understand its nature and process in different contexts has been highlighted and remains an area in which further research is needed. Understanding the point of view of students can help educators, curriculum planners and evaluators make optimal use of their opportunities and resources within HSE. Thus, the present study sought to explore students' perceptions and experiences of teamwork within a HSE context with a view to contributing to this resource base. Implicit in the study context is the occurrence of first year health sciences students coming into contact with each other in a mixed professions course “Becoming a health professional” (BHP). A theory about social interaction, contact theory, postulates that when individuals from different groups have opportunities to come together under certain conditions, positive social outcomes may result. On the contrary, contact between distinct groups could also bring about adverse effects. In this study different groups referred to students registered for different health professional degree programmes. Based on the proviso that teamwork can be associated with positive, functional interactions between people, which of contact theory's suppositions were experienced by the students in this study was explored. Since teamwork is innately a social activity which is experienced in relation to others, one of the assumptions underpinning this study was that students' perspectives of teamwork may be co-constructed. Thus, the study was positioned within an interpretivist paradigm in which reality is subjective but also co-constructed by individuals, including participants and researchers. Using a qualitative design, this exploratory study offers insight into first year students' perspectives of teamwork within the undergraduate mixed professions course BHP. The primary data production method was focus group discussion and data were evaluated using thematic analysis. The thematic analysis yielded three broad themes: the purpose of teamwork in BHP; the persons involved in teamwork; and the process of teamwork in BHP. The findings of this study revealed that students had a comprehensive perception of what teamwork entails in their educational context, although their experiences of teamwork varied. These perspectives have been linked in concrete ways to the literature reviewed in this study and its theoretical framework. Thus, the findings were used to generate a heuristic for teamwork learning for health sciences students. The impact of this study is that students' perspectives of teamwork may be useful to the future design and delivery of entry level interprofessional courses aiming to instil teamwork skills. The underlying rhetoric of this thesis is that students are capable of contributing to their own learning, and the present findings manifested in one such contribution, the development of a pedagogical tool for teamwork.

Patient-centred communication and patient education: a multimodal social semiotic approach This study explores the phenomenon of patient-centred communication within the South African health context. Patient-centred communication involves several distinct but interlinked elements, namely, taking a holistic approach to illness, 'seeing' through the patient's eyes, 'co-constructing' a shared understanding or therapeutic alliance, and sharing decision-making and responsibility where possible. While adopted by medical curricula across the world, a lack of conceptual clarity is common among students, educators, researchers and policy-makers. Furthermore, little research has been done that accounts for contextual factors and non-western settings. This study looks at how fourth year medical students operationalise the 'classroom-taught' principles of patient-centred communication during a health education encounter with patients. Drawing on a qualitative, interpretivist paradigm, the research focuses on communication in the context of language barriers, cultural value differences and socio-economic inequality. This study views students' multimodal health education artefacts as instances of 'informed flexibility' to patients' needs and challenges. The research is located within a Pharmacology curriculum activity where medical students produce personalized health promotion artefacts for rheumatic heart disease patients. Their artefacts are instances of patient-centred communication as well as instances of purposeful pedagogic recontextualisation, in that they realise both epistemic and relational dimensions of health education. Students also write a critique on the process, reflecting on the patient interview and motivating their design choices. Taking a multimodal social semiotic approach, the study draws on Bezemer and Kress' semiotic principles of recontextualisation (2008) for analysis of artefacts. Thematic analysis of students' critical reflections as well as follow-up interviews with their patients illuminate the context and assumptions underpinning students' design choices. The study is significant in several ways. It highlights the complex, multifaceted, multi-layered nature of doctor-patient communication, argues for realism in what can be taught and assessed in a classroom and suggests novel pedagogic approaches. The study also brings an African perspective to patient-centred communication, and in highlighting challenges relevant to the South African health care system, it supports contemporary calls for 'decolonisation' of health sciences curricula. The research contributes to ongoing efforts to eradicate rheumatic heart disease by giving patients a 'voice', raising awareness and supporting preventative programs. Methodologically, the study contributes to Bezemer and Kress' (2008) pursuit of articulating a semiotic methodological framework for multimodal texts.

Study problem In the education of South African postgraduate medical specialities, various challenges that could have negative impacts on learning are evident. Racial and socio-cultural diversity in South Africa has roots in a previous societal structure that systematically discriminated against particular social groups resulting in significant political, economic and social inequalities between the groupings. With the current processes of transformation underway, the sphere of training postgraduate students in medical specialities reveals visible differences in racial backgrounds between students and consultants at the training centres across the nation, with the majority of consultants being Whites and Indians, whilst the majority of students are Black Africans and a few Indians. The recent high failure rate of the summative exit examination in certain specialities has stimulated a high level of interest into how racial and socio-cultural diversity may have influenced the training and learning of postgraduate students or registrars. Theoretical framework In this thesis, a conceptual framework is used that combines dimensions from the theories of Collins (1987), Collins, Brown and Holum (1991) on cognitive apprenticeship, Vygotsky (1978), Lave and Wenger (1991) on socio-cognitive and socio-cultural learning, and Bronfenbrenner’s (1977) theory on Human Ecology. Collectively they posit that relationships are central to the quality of learning and training. The education of postgraduate students, so called registrars or intermediary novices, is structured as personal mentoring in the form of cognitive apprenticeship and their legitimate participation in the departmental Community of Practice. Learning in this context occurs through daily service provision under supervision or mentorship, as well as unscheduled informal discussions (engagement) that reflect socio-cultural learning in which novices and consultant specialists interact socially and academically. This form of learning is dependent on effective mediation and participation, which depends upon understanding, trust and mutual respect in a relationship between the two parties. This relationship could be influenced by factors such as inter-personal differences. Whether the factors translate into socio-cultural differences such as language, culture and social identities, need to be determined. Aim and objectives The aim of the study was to explore the conceptions of two student groups, one who had left the specialist programme, and the other who had recently qualified, regarding the nature of racial and socio-cultural diversity in their learning environment, the influences on their learning, and how they responded to them. Methodology Using one of the medical speciality disciplines as a focus area, a qualitative enquiry using faceto-face in-depth interviews followed by a thematic analysis of descriptive data was employed. Participants were former students who had either left the formal training programme after being unsuccessful in the summative examination and reached the end of their employment contracts, or those who had recently passed the examination and qualified as junior specialists. The interviews were semi-structured to explore participant’s learning background through schooling, undergraduate and postgraduate studies, with focus on experiences in formative learning through these stages. The participant’s family socio-cultural background was also explored. Data analysis and interpretation were done using a social constructionist epistemology where meanings were co-constructed based on multiple perspectives Findings and analysis The following themes were identified from the data analysis: Theme 1: Racial and socio-cultural differences as barriers in learning, with the sub-themes: constructing ‘race’, ‘language’, ‘culture’, and ‘feeling excluded by social status’ as barriers to learning; Theme 2: Relationships in the learning environment shaping learning, with sub-themes: ‘relationships in the early learning stage’, ‘relationships in undergraduate medicine’, and ‘relationships in postgraduate learning stage of speciality training’; Theme 3: Challenges in the learning process, with sub-themes as: ‘lack of curricular clarity’, and ‘lack of formative learning structure’; Theme 4: Resilience, with sub-themes: ‘capacity for adaption’, and ‘the ways in which resilience has been shaped by the micro- and macro-environments’. The further analysis found the socio-cultural diversity and relationships affecting engagement during formative learning themes to be inter-related, whilst sub-themes race, language, culture and social identities were also inter-connected. The curriculum, formative training, relationships, people’s perspectives and culture of the community were found to be intricate and complex, yet difficulties could still be overcome using certain attributes and skills. Conclusion Participants perceived the racial and socio-cultural diversity such as language, culture, personality and socio-economic status in the postgraduate learning environment as barriers to learning. Participants in the group who had qualified were however able to negotiate the diversity by being resilient, adaptable and emotionally mature. These attributes enabled them to navigate difficulties and remain focussed on their goal. An ability to initiate and form relationships with new peers and consultants emerged as an important feature in this group. These findings could hopefully benefit both current and future students and highlight the need to create opportunities for cross-cultural engagement activities in medical speciality training programmes.

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