Indiana University-Purdue University Indianapolis (IUPUI) / Simulation is an educational strategy used in prelicensure nursing education that has been demonstrated to effectively replace selected clinical experiences. Simulation experiences may include the use of differing roles including the active participant, who makes decisions during the simulation and the passive observer, who watches the simulation unfold. There is a lack of rigorous research testing whether students in the passive observer role during simulations demonstrate and retain knowledge similarly to those in active participant roles. In addition, differences in knowledge applied to a contextually similar case between those who actively participate and passively observe have not been studied. The purpose of this study was to explore the relationship between nursing student’s roles in simulation and cognitive knowledge demonstration, retention, and application about two contextually similar cases of respiratory distress. An experimental, pretest-multiple posttest, repeated measures study was conducted with a convenience sample of 119 baccalaureate prelicensure nursing students from a large multi-campus Southwestern university. Two knowledge instruments were administered throughout different stages of the simulation and four weeks later. Associations between role in simulation and scores on the knowledge instruments were examined using t-tests and mixed repeated measures-analysis of variance. Of the 59 active participants and 60 observers, there were no significant differences in knowledge demonstrated or retained after simulation, after debriefing, or four weeks later. Additionally, there were no significant differences in knowledge demonstrated when applied to a contextually similar case after debriefing or four weeks later between active participant and observer. Future research is needed to examine these relationships in larger and more diverse samples and different contextual clinical situations in simulation. These results will contribute to the further testing and implementation of using observation as a strategy for teaching and learning with simulation for nursing and health professions education.

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Tetralogy of Fallot (TOF) is the most common cyanotic congenital cardiac defect with a global annual incidence of 40,000 cases. Advances in surgery and perioperative care led to improvements in perioperative mortality and, thus, a growing number of survivors. TOF survivors often suffer from complications related to a failing right ventricle. Follow-up studies evaluating TOF repair strategies suggest an association between the type of surgical repair strategy and late right ventricular health. However, surgical practices remain unchanged and led by institution-level biases. The body of evidence addressing outcomes based on TOF surgical repair strategy is weak and controversies persists on the management of these patients.  This thesis comprises 6 chapters that form the foundation of a multi-centre research program on outcomes after TOF surgical repair. The program uses various methodologies to generate evidence with a vision to change surgical practices.  Chapter 1 is an introduction providing background on TOF and contemporary areas of controversy.  Chapter 2 presents the results of a retrospective analysis evaluating the use of early echocardiogram parameters in predicting late cardiac magnetic resonance imaging evaluation of the right ventricle.  Chapter 3 presents the results of a retrospective cohort exploring the association between TOF repair strategy and development of right bundle branch block.  Chapter 4 presents the results of a multinational survey aiming to explore contemporary biases in TOF surgical repair strategy selection.  Chapter 5 presents the background, rationale, design and baseline cohort characteristics of the Tetralogy of Fallot for Life (TOF LIFE) study. The study is a multi-centre inception cohort study with a follow-up period of 2 years.  Finally, Chapter 6 discusses the conclusion, limitations, and future implications of this research program. / Thesis / Doctor of Science (PhD)

The purpose of this study was to determine the effects of video modeling on skill acquisition in learning the golf swing. One-hundred-eight college students participated in this study. All participants were pre-tested via videotaping to determine initial skill level. The pre-test videotaping was analyzed using DartTrainer software. Each participant was randomly assigned to one of three groups (1) control (2) single-view or (3) multi-view. Participants in the control group viewed a compact disc (CD) with a putting demonstration repeated 40 times. The participants in the single-view group viewed a CD with a front view only demonstration repeated 40 times of the golf swing with a driver. Participants in the multi-view group viewed a CD with a multi-view (front, back, left, and right) demonstration of the golf swing using a driver. The demonstration was performed by a golf professional and each view was repeated 10 times for a total of 40 repetitions. After five weeks of CD viewing, practice, and class instruction, participants were video-taped to determine the level of improvement. Factorial ANOVA (3 groups x 2 trials) indicated significant within group pretest to posttest differences (F (1, 105) = 295.93, p<0.001). Between group differences were also noted (F, (2,105) = 18.33, p<0.001). Post hoc analysis indicated significantly fewer posttest deviations in the MV group than in the control group (p<0.001). The single-view group also had fewer posttest deviations than did the control group (p<0.001). There were no significant differences between the multi-view and single-view groups. The current study suggests that video modeling provided on a CD, which a learner can access on their own, may significantly increase skill acquisition rate and performance in learning the golf swing.

The expectation of privacy and confidentiality in health care presents a unique dilemma for public health interests. A great deal of observational health research such as epidemiological studies, disease surveillance, and quality assurance depends on access and use of personal information in the absence of individual consent. Understandably, this raises concerns about personal privacy since sensitive disclosures of information can result in harm such as stigma, discrimination, and loss of socio-economic goods. However, the issue has been largely framed and discussed as a dichotomy: the privacy interest of the individual versus the social interest in research. to individualist paradigm informed by a traditional liberal conception of privacy that emphasizes autonomy drives this dichotomy and inevitably leads to an intractable conflict. In this thesis, I attempt to re-frame the issue by moving away from individualism in shifting the focus towards confidentiality which is relational and founded on trust. I argue that confidentiality is broader than the concern for individual privacy and is thus capable of capturing other relevant interests, such as collective and social interests. I advance a broad conception of confidentiality grounded in a mixed deontic-consequentialist moral framework that can account for respect for persons and social interests. / Thesis / Doctor of Philosophy (PhD)

There is strong evidence that certain neurophysiological processes link action and observation (Higuchi et al., 2012), which supports the idea that learning a motor skill is enhanced via skill observation (Hayes et al., 2010). Skill learning through observation is optimized when the observation includes a combination of expert and novice models (Rohbanfard and Proteau, 2011). The purported advantage lies in the two types of models’ dissimilar ability (Andrieux & Proteau, 2013). The novice model is characterized by larger margins of error that manifest as variable attempts. Increased variability has been shown to be beneficial in physical practice (Moxley, 1979). The purpose of the first study was to examine the observation of novice variability effect to explore whether it is Schmidt’s (1975) generalized motor programs or schema parameterization representations that is acquired when observing modeled performances. Participants engaged in an observational period in which they observed a criterion model with no variability, a model demonstrating absolute timing variability, a model demonstrating relative timing variability, or a model demonstrating variability in both relative and absolute timing. The results indicate that variability in relative timing information contributes to observational learning, which suggests that generalized motor programs are acquired through observation but not schematic parameterizations. The purpose of the second study was to apply the Rohbanfard and Proteau (2011) paradigm in the medical education context by exploring the impact of video-based observational practice on the clinical learning. First year medical students learned a common surgical skill by observing expert demonstrations of the skill, novice demonstrations, or demonstrations by both an expert and novice model. The study demonstrated a robust effect of observational learning in that all groups improved over time regardless of the type of model they observed. Both studies highlight that an expert model may be the most beneficial when engaging in observational practice. / Thesis / Master of Science (MSc)

Background and objectives: Prediction models are useful tools in clinical practise by providing predictive estimates of outcome probabilities to aid in decision making. As biomedical research advances, concerns have been raised regarding combined effectiveness (benefit) and safety (harm) outcomes in a prediction model, while typically different prediction models only focus on predictions of separate outcomes. A second issue is that, evidence also reveals poor predictive accuracy in different populations and settings for some prediction models, requiring model calibration or redevelopment. A third issue in data analyses is whether the treatment effect estimates could be influenced by competing risk bias. If other events preclude the outcomes of interest, these events would compete with the outcomes and thus fundamentally change the probability of the outcomes of interest. Failure to recognize the existence of competing risk or to account for it may result in misleading conclusions in health research. Therefore in this thesis, we explored three methodological issues in prediction models and data analyses by: (1) developing and externally validating a prediction model for patients’ individual combined benefit and harm outcomes (stroke with no major bleeding, major bleeding with no stroke, neither event, or both stroke and major bleeding) with and without warfarin therapy for atrial fibrillation; (2) constructing a prediction model for hospital mortality in medical-surgical critically ill patients; and (3) performing a competing risk analysis to assess the efficacy of the low molecular weight heparin dalteparin versus unfractionated heparin in venous thromboembolism in medical-surgical critically ill patients. Methods: Project 1: Using the Kaiser Permanente Colorado (KPCO) anticoagulation management cohort in the Denver-Boulder metropolitan area of Colorado in the United States to include patients with AF who were and were not prescribed warfarin therapy, we used a new approach to build a prediction model of individual combined benefit and harm outcomes related to warfarin therapy (stroke with no major bleeding, major bleeding with no stroke, neither event, or both stroke and major bleeding) in patients with AF. We utilized a polytomous logistic regression (PLR) model to identify risk factors and then construct the new prediction model. Model performances and validation were evaluated systematically in the study. Project 2: We used data from a multicenter randomized controlled trial named Prophylaxis for Thromboembolism in Critical Care Trial (PROTECT) to develop a new prediction model for hospital mortality in critically ill medical-surgical patients receiving heparin thromboprophylaxis. We first identified risk factors independent of APACHE (Acute Physiology and Chronic Health Evaluation) II score for hospital mortality, and then combined the identified risk factors and APACHE II score to build the new prediction model. Model performances were compared between the new prediction model and the APACHE II score. Project 3: We re-analyzed the data from PROTECT to perform a sensitivity analysis based on a competing risk analysis to investigate the efficacy of dalteparin versus unfractionated heparin in preventing venous thromboembolism in medical-surgical critically ill patients, taking all-cause death as a competing risk for venous thromboembolism. Results from the competing risk analysis were compared with findings from the cause-specific analysis. Results and Conclusions: Project 1: The PLR model could simultaneously predict risk of individual combined benefit and harm outcomes in patients with and without warfarin therapy for AF. The prediction model was a good fit, had acceptable discrimination and calibration, and was internally and externally validated. Should this approach be validated in other patient populations, it has potential advantages over existing risk stratification approaches. Project 2: The new model combining other risk factors and APACHE II score was a good fit, well calibrated and internally validated. However, the discriminative ability of the prediction model was not satisfactory. Compared with the APACHE II score alone, the new prediction model increased data collection, was more complex but did not substantially improve discriminative ability. Project 3: The competing risk analysis yielded no significant effect of dalteparin compared with unfractionated heparin on proximal leg deep vein thromboses, but a lower risk of pulmonary embolism in critically ill medical-surgical patients. Findings from the competing risk analysis were similar to results from the cause-specific analysis. / Thesis / Doctor of Philosophy (PhD)

Hip fractures are common injuries with devastating consequences, including high rates of morbidity and mortality. The purpose of my thesis was to lay the foundation for further research which can fully explore: i) the epidemiology of morbidity and mortality following hip fracture; ii) risk factors for poor outcomes following hip fracture; iii) causes and pathways to mortality following hip fracture; iv) secondary prevention of morbidity and mortality following hip fracture; and v) potential interventions to improve outcomes following hip fracture. To this end, I will first detail the design, execution, results, and ‘lessons learned’ of a prospective observational pilot cohort study that recruited 100 consecutive patients aged ≥18 years presenting with a hip fracture to the Juravinski Hospital and Cancer Centre of the Hamilton Health Sciences. The primary aim of this pilot study was to assess the feasibility of a larger prospective international cohort study. Second, I will present a systematic review and meta-analysis of a promising intervention that consisted of multi-disciplinary (specifically geriatrician-led) co-management of hip fracture patients. This intervention has previously been shown to reduce mortality and length of stay following hip fracture. The meta-analysis presented will determine the effectiveness of this intervention in reducing the incidence, duration, and severity of delirium—a common condition following hip fracture. / Thesis / Master of Science (MSc)

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