With an aging population and with the number of patients with large prosthetic joints increasing, the recommendation of antibiotic use in this specific population has generated significant discussion. Dentists often treat patients with large prosthetic joints; however, little is known regarding the prescribing practices of dental providers. This cross-sectional study carried out in the State of Iowa, United States, evaluated whether dentists were familiar, followed, and were satisfied with the 2015 American Dental Association Clinical Guidelines and the 2016 American Academy of Orthopaedic Surgeons Appropriate Use Criteria (AUC), and whether dentists responses were associated with demographic and provider characteristics. Dentists’ concerns about antibiotic resistance, medical legal aspects, and adverse effects related to using antibiotic prophylaxis were also examined. Of the 1521 surveys that were sent by mail, a total of 635 were returned, for a response rate of 41.7%. Our results confirm that dental practitioners were very concerned about antibiotic resistance (43.9%) compared to 5.23% who were not at all concerned. In addition, female subjects were significantly more likely to be very concerned about antibiotic resistance than were male subjects (50.9% vs 41.4%; p=0.0376). Moreover, subjects that practiced in urban areas were more likely to be very concerned about antibiotic resistance that those practicing in rural areas (47.9%vs 37.5%; p=0.0157). We also observed that for a healthy patient, 28.9% of dentists would never recommend antibiotics. On the other hand, 44.9% of the respondents would recommend antibiotic premedication within the first 2 years since prosthetic joint replacement, 14.1% would recommend it within the first year, and 6.9% would recommend it for life. Dentists were aware of the lack of effectiveness of antibiotic prophylaxis in preventing prosthetic joint infection. However, premedication recommendations by physicians and patient preferences influenced dentist’s prescribing practices. Overall, dentists’ recommendations for the use of antibiotic for patients with prosthetic joints undergoing dental procedures varied depending on the health status of the patient, the dental procedure to be performed, the time since joint surgery, physician’s recommendations and patients preferences.

Objectives: To evaluate the oral health knowledge of legally authorized representatives of long term care facility residents to assess whether oral health knowledge is associated with the representatives’ understanding of the residents’ oral health status and treatment needs. Methods: The study participants were legally authorized representatives (LARs) of long term care facility (LTCF) residents who were visited by the Geriatric Mobile Unit (GMU) of the University of Iowa College of Dentistry & Dental Clinics. Once IRB approval was obtained, a mailing was sent out to the LARs after the GMU visited the LTCF. LARs were asked to complete a survey and were also asked permission to obtain dental records of the LTCF resident they represented. The survey contained questions pertaining to the LAR as well as the LTCF resident. With respect to the LAR, questions on socio-demographics, oral health literacy, oral health knowledge, oral health behavior and oral health status were asked. For questions about the LTCF resident, the LARs were asked about the resident’s prior oral health behavior, current oral health status, oral health treatment needs, and dental insurance status. They were also asked what factors would influence their decision to seek oral health care for the LTCF resident, and when they last spoke to the LTCF resident about their oral health. Bivariate analyses were conducted using Chi-square and Cochran-Mantel-Haenszel tests with LARs knowledge about the LTCF residents’ missing teeth and various oral health treatment needs being the outcome variables. Significant variables were entered into a multiple logistic regression model for each outcome variables. Statistical significance was set at p<0.05 and p=0.05-0.2. Results: Four hundred and thirty-one surveys were mailed out to the LARs. One hundred LARs consented to participate in the study and returned the completed questionnaire. Fifty-two percent of the LARs got all nine oral health knowledge questions correct. The questions that were the most frequently missed included “Losing teeth is a natural process of aging” (77% answered correctly), and “Blood on your toothbrush is a sign of gum disease” (74% answered in correctly). Thirty-eight percent of the LARs said they were extremely confident filling out medical forms by themselves, and 37% said they were quite a bit confident. When asked about the missing teeth of the LTCF resident, ten LARs reported that their LTCF resident had all teeth missing, while only 9 LTCF residents had all teeth missing as per chart review. Seventy-six residents had some upper back teeth missing and 71 residents had some lower back teeth missing. Twenty-eight LARs reported some upper back teeth were missing in their resident and 24 LARs reported some lower back teeth was missing. Treatment needs of the resident were in general underestimated by the LAR. Thirty-five LTCF residents needed a filling and 15 needed extractions, however LARs reported 21 residents needed fillings, and 8 needed extractions. Fifty-six LARs did not know if the resident needed a filling, and 49 LARs did not know if the resident needed an extraction. Bivariate analyses reported a number of significant variables in each domain for p values <0.05 and between 0.05 and 0.2. In the final logistic regression model, retirement status of the LAR and LARs’ confidence filling out medical forms were most commonly significant for LARs’ knowledge about treatment needs of the LTCF resident; and self-reported oral health status, age of the resident, and physical health status of the resident influencing the LARs decision to seek care dental care for the resident were significant for LARs’ knowledge about missing teeth of the LTCF resident. Conclusion: Although the majority of LARs indicated that oral health is important for nursing home residents, many LARs were unaware of the oral health status and the treatment needs of the LTCF residents. While a single variable was not found to be commonly associated across LARs’ knowledge of the oral health status and treatment needs of the residents, several variables were associated with the knowledge of one treatment need only as opposed to the knowledge of multiple treatment needs. Understanding if and how oral health literacy and oral health knowledge influence LARs’ and as well as nursing home caregivers’ decisions to seek dental care for LTCF residents may help address the gaps in oral health care for LTCF residents, thereby improving their quality of life.

Little research has been done to identify effectiveness in nursing practice. This is especially true in home care nursing practice. Nurse leaders and educators express concern for effectiveness, and the profession seems to be advancing in the development of that body of knowledge. The purpose of this study was to examine effectiveness in home care from the perspectives of those intimately involved with its enactment: the nurse, the nurse supervisor, and the client. Conceptually organized within the particular philosophic context of the interpretive paradigm, this study employed the ethnographic methodology of focused interviews as the main resource for gathering data. Findings. The definition of effective nursing was a complex mixture of structure, process, and outcome activities. There were shared perceptions among the subjects and subject groups in this study about knowledge, skills, and personal qualifications and attributes of the effective nurse. There was also considerable agreement about effective home care nursing behaviors which included a range of complex clinical activities, communication, teaching, and the ability to cultivate family involvement. Each sample group also identified unique categories of effective home care nursing behaviors based on its own subjective view of ideal practice. Effective care outcomes were not readily identified by any of the groups except in vague terms. The implications for nursing practice, education, and research were discussed.

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.

This qualitative study explored the effects of trauma as well as coping mechanisms used to deal with post-traumatic stress experienced by ILS paramedics providing emergency care services in the Gauteng Province, South Africa. It also looked at the competencies needed to cope with traumatic stress and promote biopsychosocial well-being. It is argued that it is important to look at this subject from a South African perspective since most of the published research on the sources and effects of trauma on paramedics and other frontline emergency services personnel experience comes from developed countries. It was discovered that there is minimal empirical research from South Africa on similar topics, except for a study in the Cape Town metropole. In addition to that, most published research relied on quantitative data collection methods. Through qualitative case study research this thesis draws on observations and relevant data gathered by way of semi-structured face to face interviews with eleven operational Intermediate Life Support (ILS) paramedics who work in the Gauteng province. Data is gathered on the sources of stress and coping mechanisms currently used by the paramedics. The gathered data was analysed using thematic analysis. The results show that the sources of stress for paramedics include attending gruesome scenes, extreme pressure to save lives and attending a scene where a child or a colleague is involved. It was also observed that the paramedics have a set of coping strategies to manage post-traumatic stress which are both positive and negative coping strategies. In addition to interviews with ILS paramedics from whom data is gathered on their education and training, the results in this thesis gathered insight from a panel of six experts who were engaged through a focus group discussion. These experts have demonstrable expertise in curriculum development, trauma counselling and training. The panel recommended that the training of the paramedics must be more realistic such that the paramedics are better equipped to deal with the challenges they may encounter in the work environment. It was also revealed that those who train paramedics are not well equipped to deliver the health and wellness module. It can be concluded that some paramedics are not well equipped to deal with traumatic events they encounter in the field. The researcher recommends that the health and wellness module be delivered by people who are specifically trained to deal with mental health issues. Insights gathered in this study will help the paramedics, those they help and their families.

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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