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.

Many entry-level nurses are not prepared to handle medical emergencies. Although responsible for managing the care of individuals with complex medical conditions, many of these nurses compromise the safety of patients due to a lack of experience and an inability to apply clinical judgment. The purpose of this study was to explore the perceptions of registered nurses about their transition from entry-level to advanced beginner. Bandura's social cognitive theory, along with Colaizzi's descriptive method of data analysis, provided a basis for this phenomenological study. Research questions focused on challenges that entry-level nurses have experienced with problem-solving and complex patient care that requires advanced critical thinking and the application of clinical judgment. Criterion sampling facilitated recruitment of advanced-beginner RNs, with data collected through semistructured, one-on-one interviews. Data analysis occurred in a series of steps, including extracting and developing meanings from interview transcripts, clustering meanings into description lists, and eliminating outliers. Data analysis revealed 12 major themes aligned with behavior, clinical environment, and personal/cognitive factors. Among the findings were that nurses often felt unsupported, unable to manage conflict, unprepared, unseasoned, inefficient, and unable to lead others effectively. This study was necessary because its findings may provide insights leaders in health services can use to develop strategies to better prepare entry-level nurses to care for individuals with complex medical conditions. Among the implications for positive social change are developing a better tool for the training and advancement of entry-level nurses, consequently improving patient safety and reducing health care costs.

Face aux nombreuses difficultés environnementales et sociales auxquelles l'agriculture doit faire face, des pratiques basées sur la gestion de processus écologiques ont été proposées comme des solutions possibles. Or de telles pratiques, dites agroécologiques, ne peuvent résulter d'une simple application de recettes techniques, et doivent être développées en lien étroit avec les caractéristiques écologiques et autres du système géré par chaque agriculteur. En conséquence, il est nécessaire d'envisager une évolution du système de production et de diffusion de savoirs, avec en particulier une place importante à donner aux agriculteurs eux-mêmes dans le développement de leurs propres pratiques. L'objectif de cette thèse est donc de mieux comprendre comment les agriculteurs apprennent à développer des pratiques agroécologiques, afin de contribuer à l'accompagnement d'autres agriculteurs dans leur propre transition vers ce type de pratiques. Nous nous concentrons sur l'agriculture de conservation, qui se fonde sur trois grands principes : la réduction du travail du sol, la diversification des cultures et la couverture permanente du sol. A l'aide d'éléments théoriques issus de la philosophie pragmatiste, nous analysons qualitativement des entretiens réalisés chez des agriculteurs expérimentés en agriculture de conservation dans plusieurs régions de France. Cela nous amène dans un premier temps à proposer un cadre pour décrire les processus d'apprentissage et les jugements pragmatiques qui se développent au cours de ceux-ci. Nous précisons ensuite les évolutions possibles des jugements pragmatiques, et les particularités des processus d'apprentissage qui permettent ces différentes évolutions. Enfin, nous nous intéressons à la diversité entre agriculteurs dans les façons d'apprendre, notamment en mettant en regard les différentes trajectoires de changements vers l'agriculture de conservation. Nos résultats nous amènent à proposer des pistes pour l'accompagnement de l'apprentissage des agriculteurs : nous suggérons entre autres qu'il est important de valoriser la diversité des façons d'apprendre, mais sans chercher à la réduire à des styles d'apprentissage fixes, et nous proposons une application possible de la théorie de la communication engageante pour participer à l'accompagnement vers des pratiques d'agriculture de conservation. Enfin, nos résultats nous amènent à réfléchir à l'agroécologie non pas seulement comme un objectif du développement agricole, mais aussi comme un moyen de développement pour les individus. / Agriculture is facing multiple environmental and social challenges; in order to address them, practices based on the management of ecological processes have been pointed out as possible solutions. Such practices, known as agroecological, cannot be the result of a simple application of technical recipes: they must be developed locally, in close interaction with the ecological characteristics of the system managed by each farmer. Consequently, it is necessary to consider the evolution of the knowledge production and diffusion system, with the farmers as developers of their own practices having an especially important role. Therefore, the goal of this work is to better understand how farmers learn to develop agroecological practices in order to contribute to the support of other farmers in their own transition towards similar practices. We focus on conservation agriculture, which is based on three main principles: reduction of soil disturbance, crop diversification, and permanent soil cover. With the help of theoretical elements grounded in pragmatist philosophy, we qualitatively analyze interviews conducted with farmers experienced in conservation agriculture in different regions of France. This leads us to the proposal of a framework to describe the learning processes and the pragmatic judgements that develop along these processes. We then specify the possible developments of pragmatic judgements, and the specificities of the learning processes that allow such changes. Finally, we focus on individual characteristics of the learning processes, studying them partly through contrasting farmers' trajectories of changes toward conservation agriculture practices. Our results enable us to make different suggestions for the support of farmers' learning: we argue that it is important to take into account the diversity of learning processes without reducing it into a typology of learning styles, and we discuss a possible application of the binding communication theory to facilitate the transition toward conservation agriculture practices. Ultimately, our results suggest that we should think about agroecology not only as a goal for agricultural development, but also as a means for the development of individuals.

Contemporary theories of learning suggest that successful learners are active in the learning process and that they tend to use a number of metacognitive processes to monitor learning and remembering. Drawing on the theoretical framework of Nelson and Narens (1992), the current study examined the effect of certain variables on metamemory processes and on students' ability to recall and recognise learned material. The present study explored the effect of four independent variables on five dependent variables. The independent variables were: 1. degree of learning (responses given until 2 or 8 times correct), 2. judgment of learning (JOL) timing (given immediately after learning session or 24 hours later), 3. retention interval between study and test (2 or 6 weeks), and 4. type of material studied (sentences, in or out of context). The dependent variables were: 1. judgement of learning (JOL), 2. confidence rating, 3. feeling of knowing (FOK), 4. recall, and 5. recognition.. As ancillary analyses, the study explored, firstly, whether gender differences had an effect on meta-level and object-level memory, and secondly, whether students who recalled more also made more accurate metamemory judgements. The effects of the independent variables on recall and recognition were consistent with those found by previous studies. The most interesting new finding of the present study was that students who made JOLs after twenty four hours were more likely to take into account the effect of the interval between learning and testing. Students who made immediate JOLs did not allow for the effect of the time interval on retention. A further new finding was that gender appeared to have had an influence on JOLs. The findings about the effects of timing of JOLs and of gender effects on JOL have implications for metacognitive theory and will stimulate further research. The practical significance of this research, particularly the implications for study skills training for all students, was that educators cannot presume that students will correctly predict what they will recall after six weeks if they make that judgement immediately after learning has occurred. Therefore, the effects of the passage of time on memory, and the efficacy of delaying judgments, should be made explicit. The finding that the manipulation of JOL timing has a significant effect on the accuracy of judgements has implications in the wider area of educational policymaking and for the current debate on competencies and quality assurance. Learning cannot be considered a simple process and when a large component of learning is selfdirected, as it is in tertiary institutions and increasingly in schools, many variables are operating.

Quantitative microbial risk assessment (QMRA) is being increasingly used to support decision-making for food safety issues. Decision-makers need to know whether these QMRA results can be trusted, especially when urgent and important decisions have to be made. This can be achieved by setting up a quality assurance (QA) framework for QMRA. A Belgian risk assessment project (the METZOON project) aiming to assess the risk of human salmonellosis due to the consumption of fresh minced pork meat was used as a case study to develop and implement QA methods for the evaluation of the quality of input data, expert opinion, model assumptions, and the quality of the QMRA model (the METZOON model). The first part of this thesis consists of a literature review of available QA methods of interest in QMRA (chapter 2). In the next experimental part, different QA methods were applied to the METZOON model. A structured expert elicitation study (chapter 4) was set up to fill in missing parameters for the METZOON model. Judgements of experts were used to derive subjective probability density functions (PDFs) to quantify the uncertainty on the model input parameters. The elicitation was based on Cookes classical model (Cooke, 1991) which aims to achieve a rational consensus about the elicitation protocol and allowed comparing different weighting schemes for the aggregation of the experts PDFs. Unique to this method was the fact that the performance of experts as probability assessors was measured by the experts ability to correctly and precisely provide estimates for a set of seed variables (=variables from the experts area of expertise for which the true values were known to the analyst). The weighting scheme using the experts performance on a set of calibration variables was chosen to obtain the combined uncertainty distributions of lacking parameters for the METZOON model. A novel method for the assessment of data quality, known as the NUSAP (Numeral Unit Spread Assessment Pedigree) system (chapter 5) was tested to screen the quality of the METZOON input parameters. First, an inventory with the essential characteristics of parameters including the source of information, the sampling methodology and distributional characteristics was established. Subsequently the quality of these parameters was evaluated and scored by experts using objective criteria (proxy, empirical basis, methodological rigour and validation). The NUSAP method allowed to debate on the quality of the parameters within the members of the risk assessment team using a structured format. The quality evaluation was supported by graphical representations which facilitated decisions on the inclusion or exclusion of inputs into the model. It is well known that assumptions and subjective choices can have a large impact on the output of a risk assessment. To assess the value-ladenness (degree of subjectivity) of assumptions in the METZOON model a structured approach based on the protocol by Kloprogge et al. (2005) was chosen (chapter 6). The key assumptions for the METZOON model were first identified and then evaluated by experts in a workshop using four criteria: the influence of situational limitations, the plausibility, the choice space and the agreement among peers. The quality of the assumptions was graphically represented (using kite diagrams, pedigree charts and diagnostic diagrams) and allowed to identify assumptions characterised by high degree of subjectivity and high expected influence on the model results, which can be considered as weak links in the model. The quality assessment of the assumptions was taken into account to modify parts of the METZOON model, and allows to increase the transparency in the QMRA process. In a last application of a QA method, a quality audit checklist (Paisley, 2007) was used to critically review and score the quality of the METZOON model and to identify its strengths and weaknesses (chapter 7). A high total score (87%) was obtained by reviewing the METZOON model with the Paisley-checklist. A higher score would have been obtained if the model was subjected to external peer review, if a sensitivity analysis, validation of the model with recent data, updating/replacing expert judgement data with empirical data was carried out. It would also be advisable to repeat the NUSAP/Pedigree on the input data and assumptions of the final model. The checklist can be used in its current form to evaluate QMRA models and to support model improvements from the early phases of development up to the finalised model for internal as well as for external peer review of QMRAs. The applied QA methods were found useful to improve the transparency in the QMRA process and to open the debate about the relevance (fitness for purpose) of a QMRA. A pragmatic approach by combining several QA methods is recommendable, as the application of one QA method often facilitates the application of another method. Many QA methods (NUSAP, structured expert judgement, checklists) are however not yet or insufficiently described in QMRA related guidelines (at EFSA and WHO level). Another limiting factor is the time and resources which need to be taken into account as well. To understand the degree of quality required from a QMRA a clear communication with the risk managers is required. It is therefore necessary to strengthen the training in QA methods and in the communication of its results. Understanding the usefulness of these QA methods could improve among the risk analysis actors when they will be tested in large number of QMRAs.

Background: A company’s choice of capital structure is influenced by the access to internal and external capital but also by the opportunities and threats that the management perceives in the environment and the management’s attitude towards risk. How an individual perceives and interpret the environment depends on the cognitive structures, which are shaped by personality, background and earlier experiences. Accordingly cognitive structures can be expected to influence the choice of capital structure. Purpose: Out of a cognitive perspective we intend to study the relationship between the way a company views it’s environment and what capital structure it chooses to have, in order to contribute to an increased understanding about what lies behind a company’s capital structure policy. Delimitations: Debt policy refers to the choice of capital structure. Cognition is briefly presented as a phenomena and in relation to risk judgement in decision processes. Realization: Our empirical studies are based on information from the annual reports of H&M, JC and Lindex from the period of 1989-2000. Results: The studied companies have a very similar view on the environment and their capital structures are relatively similar since all of them have a high share of equity. Consequently the choice of capital structure can be said to be influenced by the company’s view on the environment even though this is not the only influencing factor.

This thesis examines the role of face-to-face interactions on individual choice. In particular, I explore the effect of face-to-face requests (compared to other forms of requests) on compliance. I propose that individuals expect facial feedback from their interactive partner in response to their decisions and behaviors in face-to-face interactions. In an effort to avoid anticipated negative feedback, people comply with the request. Drawing from literature on compliance, the face, face-to-face interactions, empathy, and anticipation, I develop and test this proposed theoretical account in five experiments. 1) Experiment 1 demonstrates the effect of face-to-face interactions on compliance with requests relative to other forms of making the requests and rules out some alternative explanations. 2) Experiment 2 replicates the effect in a real world setting, and shows that the effect can be moderated by sensitizing individuals to the face. 3) Experiment 3 shows that the effect can be moderated by facial expressiveness and sensitivity to face. Experiment 3 also shows that anticipation of feedback (rather than actual feedback) drives the effect. 4) Experiment 4 shows that the effect can be moderated by the expressiveness, timeliness, and consistency of facial feedback. It provides further evidence for the role of anticipated facial feedback. 5) Experiment 5 shows that individuals strategically choose different modes of interaction (i.e., face-to-face or impersonal) as a function of the feedback they expect to receive. Theoretically, this thesis provides a new understanding of how face-to-face interactions and facial expressiveness impact individual choice. In contrast to previous research, I examine the feedback mechanism that such interactions create, and the role of facial expressiveness. By providing an account in which the anticipation of feedback plays a role, this research provides a way of extending the effect of face-to-face interactions on individual compliance to faceless transactions. Moreover, I identify and test the effect of three dimensions of facial expressiveness on individual choice, thereby adding to marketing literature, compliance literature, and communication literature. The current research has managerial implications in personal selling, customer service, employee training, and online transactions.

This thesis examines the role of face-to-face interactions on individual choice. In particular, I explore the effect of face-to-face requests (compared to other forms of requests) on compliance. I propose that individuals expect facial feedback from their interactive partner in response to their decisions and behaviors in face-to-face interactions. In an effort to avoid anticipated negative feedback, people comply with the request. Drawing from literature on compliance, the face, face-to-face interactions, empathy, and anticipation, I develop and test this proposed theoretical account in five experiments. 1) Experiment 1 demonstrates the effect of face-to-face interactions on compliance with requests relative to other forms of making the requests and rules out some alternative explanations. 2) Experiment 2 replicates the effect in a real world setting, and shows that the effect can be moderated by sensitizing individuals to the face. 3) Experiment 3 shows that the effect can be moderated by facial expressiveness and sensitivity to face. Experiment 3 also shows that anticipation of feedback (rather than actual feedback) drives the effect. 4) Experiment 4 shows that the effect can be moderated by the expressiveness, timeliness, and consistency of facial feedback. It provides further evidence for the role of anticipated facial feedback. 5) Experiment 5 shows that individuals strategically choose different modes of interaction (i.e., face-to-face or impersonal) as a function of the feedback they expect to receive. Theoretically, this thesis provides a new understanding of how face-to-face interactions and facial expressiveness impact individual choice. In contrast to previous research, I examine the feedback mechanism that such interactions create, and the role of facial expressiveness. By providing an account in which the anticipation of feedback plays a role, this research provides a way of extending the effect of face-to-face interactions on individual compliance to faceless transactions. Moreover, I identify and test the effect of three dimensions of facial expressiveness on individual choice, thereby adding to marketing literature, compliance literature, and communication literature. The current research has managerial implications in personal selling, customer service, employee training, and online transactions.

Principals are required to continuously exercise their discretion on a variety of matters that affect schools, teachers, children and communities. In spite of this reality, not much study has been done in this area of the principal’s job. In this study I examine discretionary decision-making in areas of discipline, budgets and staff management. I found that principals seek to balance the needs of their students against defensibility of their actions within the context of seemingly conflicting school board policies, school policies and superintendents expectations. I present a new conceptual model for discretion and a call for careful policy writing, increased understanding of discretion by administrators and further studies which would include the perspectives of those affected by principals’ decisions. / May 2006

Den 15 juli 2008 infördes individuella utvecklingsplaner med skriftliga omdömen i svenska skolan. Det innebär att läraren vid utvecklingssamtalen ska lämna skriftlig information om elevens kunskapsutveckling i förhållande till de nationella målen i alla ämnen eleven undervisas i. Med skriftlig information menas Iup med skriftliga omdömen. Den här kvalitativa litteraturstudien belyser hur skriftliga omdömen och bedömning uttrycks i statliga styrdokument och i litteraturen. Resultaten från studien lyfter bland annat fram styrdokumentens ökade krav på skolans samarbete med hemmen och elevens ökade ansvar för sin egen kunskapsutveckling. Forskningen visar hur viktigt det är att lärare skriver omdömen kopplade till de nationella kunskapskraven och att de skriftliga omdömena formuleras med kunskap om bedömningens betydelse för både lärare och elev. Tydliga kriterier av vad som bedöms gör det också tydligt vad som inte bedöms. Utvärdering och återkoppling av elevens resultat, skolans undervisning och lärares arbete främjar elevens kunskapsutveckling och är då bedömning för lärande. Studiens resultat visar att kraven på den ökande dokumentationen i skolan riskerar att göra det enkelt mätbara till det väsentliga, istället för att göra det väsentliga mätbart. Dokumentering och formulering av skriftliga omdömen upptar en stor del av lärares arbetstid och studien visar att implementeringen av de skriftliga omdömena varit svårare än förväntat. De skriftliga omdömena kan ses som ett led i en kvalitetshöjning av skolan för att öka den internationella konkurrenskraften.