Thesis (M.S.)--University of Michigan, 1989.

Thesis (M.S.)--University of Michigan, 1989.

A professional practice instructor (PPI), as an evaluator of student performance in professional practice, makes important decisions as to whether nursing students are meeting course requirements. Several nursing education studies have reported that students whose performances are deemed unsatisfactory in professional practice courses nonetheless continue to receive passing grades. While this phenomenon, known as “failure to fail,” has been documented in studies involving nursing preceptors, it has yet to be the subject of an in-depth exploration among PPIs. Utilizing Gadamer’s (2011) philosophical hermeneutics and Fleming, Gaidys, and Robb’s (2003) hermeneutic methodology, this qualitative study sought to gain an in-depth understanding of the experiences of PPIs (n = 8) in evaluating unsatisfactory student performance within three educational institutions using a collaborative undergraduate nursing program (UNP) in Southern Ontario. This study revealed that evaluating unsatisfactory student performance is an emotionally draining experience for PPIs. The perception of an overwhelming workload and complex challenges can make it difficult for PPIs to assign a failing grade to a student, especially among novice PPIs. Furthermore, both assigning a failing grade and failing to fail students were found to have a negative impact on all participants in this study. Amid these difficulties, ongoing critical reflection and seeking collegial support and feedback were deemed helpful in validating a PPI’s decision-making, as well as alleviating the emotional aspects of grading experiences. While this study reinforces that stressors are inevitable when evaluating unsatisfactory student performance, they may be ameliorated through the creation of mandatory multi-modal orientation programs for all PPIs within educational nursing institutions. Furthermore, mentorship programs for novice PPIs might better prepare and support them in coping with the complex issues related to managing failing students. / Dissertation / Doctor of Philosophy (PhD)

<p><strong>Abstract</strong></p> <p>Health care practice environments are central to the safety and quality of patient care. Hospitals often develop and implement a professional practice model (PPM) to improve practice environments. In the United States, magnet hospital designation is a driving force in PPM implementation. In Ontario, Canada, despite the lack of magnet hospital designation, many hospitals have implemented PPMs. There appear to be differences in how PPMs are implemented in Ontario.</p> <p>This phenomenographic study examined professional practice experts’ conceptions of PPM implementation and use in Ontario acute care hospitals. The findings indicate that PPM implementation is a dynamic and emergent phenomenon that occurs in cyclical phases of growth and reduced activity.</p> <p>Seven categories of PPM use are described (a) creating alignment/consistency, (b) supporting evidence-based practice, (c) enabling interprofessional practice, (d) enhancing professional accountability, (e) enabling patient-centred care, (f) creating/ strengthening linkages, and (g) strategic positioning of professional practice. Categories exhibited hierarchical relationships, with more foundational uses providing support for higher level uses.</p> <p>Three structural themes are identified (a) model design/structure, (b) professional practice leadership, and (c) organizational support. These themes work individually and synergistically, within and across the categories to influence use and potential impact of the PPM. Progressively fuller and more complex use of the PPM appears to occur under increasingly intense influence of the structural themes.</p> <p>The analysis provides unique information about relationships within and among categories of PPM use. This provides insight regarding how organizations might maximize return on investment with PPM implementation. Seven recommendations are identified.</p> / Master of Science (MSc)

This thesis deals with the way that values get taken up by managers and leaders in international non-governmental organisations (INGOs), organisations which already have a rich history of public appeals to values. By ”values‘ I take to mean those generalised and idealising statements, such as the aspiration to ”mutual respect‘, ”equity and justice‘ ”honesty and transparency‘ in dealings with others, which usually accompany the organisation‘s vision and mission statements. The thesis sets out the argument that modern management methods based on systems thinking have been imported largely uncritically into the INGO sector, and in situations where the future is uncertain, or where there is difficulty or conflict, managers often attempt to cover over this conflict or uncertainty with an appeal to values which pictures an idealised future or an imaginary unity. Further, the thesis attempts to explore this phenomenon and to uncover some of the ethical issues that arise in the process of an appeal to unity when I am engaged as a consultant in working with managers in the INGO-sector. The thesis considers how my own practice as a consultant has changed and developed as a consequence of considering these phenomena more intensely and acting on the conclusions from these reflections. The research was prompted by my feelings of being co-opted into a process that encouraged conformity in INGOs in a way that left me feeling uncomfortable. In exploration of this discomfort and as student in a faculty pursuing the conceptual development of professional practice I have drawn broadly on the phenomenological tradition of research as a way of better understanding what I was encountering and how to make better sense of it. The method underpinning this thesis uses narrative, and reflection on narrative with a community of enquirers, which has included both fellow students on the course, as well as a wider group of interested academics. I have used as my research material my own experience of working with INGOs as a consultant and have reflected on those occasions when the discussion of values is very much to the fore. It has also meant my locating the discussion of values in a wider discourse of philosophy, sociology and psychology and mounting a critique of the dominant paradigm for understanding values in current management and organisational change literature, which is often understood as a tool for management to bring about employee alignment. Instead, I have set out an emergent understanding of values as radically social phenomena arising in the daily interaction between engaged human beings. I argue that, because of our interdependence, we are obliged to renegotiate our value commitments on a daily basis as a way of working out how we can continue together. This has involved developing a different understanding of the relationship between self and other, and a more nuanced insight into the workings of groups and the relationships of power that arise between people. Engaging with values in INGOs as a consultant invited into conversations in INGOs has thus involved my paying attention to power relating between myself and others, and the dialectic between the good and the right. Reflecting on the ethical aspects of my own consultancy practice has involved an investigation into what we might mean by ethical practice, which is generally understood to be following a series of linear rules and paradigms. I have begun to develop in its stead a theory of consultancy practice based on concepts of mutual recognition and mutual adjustment that create more space for movement within the broader social processes that can severely constrain what it is and is not possible to say and do. This thesis contributes to knowledge in the field of the management of INGOs by being one of the first to offer a critique of accepted paradigms of management theory, particularly as it relates to the appeal to values as part of strategy formation. Moreover, the emergent and social theory of values that I develop as a foil to more orthodox understandings of the role of values in the management of INGOs is also unique. My arguments concerning the ethical practice of consultancy in the domain, underpinned by a dialectical engagement of self and other, are particularly relevant to the field in which I am involved where the encounter with difference is inevitable. In the literature on management of INGOs, where research on consultancy practice is still rather thin and orthodox, my argument for a different understanding of ethical practice offers a considerable divergence of approach. In pointing to the similarities between the pressures facing INGO and private sector organisations I have also called into question the uniqueness that many scholars claim for the current management practice in INGOs. My attempts to use narrative and reflection on narrative as a method that strives to articulate what a different practice might look like should also make a new contribution to the debate about method, and ways of discussing management practice, in international development.

This thesis explores the relationship between physicians’ clinical and educational roles in the context of UK General Practice (GP) education by investigating the experiences of seven GP trainers through an ethnographic approach employing Activity Theory (AT). The Introduction considers the philosophy and structures of GP education and outlines the author’s professional biography to provide context. The Literature Review focusses on the development of medical education as a discrete field and identity formation in medical educators, concluding that: specialist medical educators are a relatively new group; and there is a paucity of knowledge regarding the impact on physicians of occupying dual clinical and educational roles. The thesis then focusses on three Research Questions (RQs), namely: 1. What is the impact of GP trainers’ clinical practice upon their educational work? 2. How does GP trainers’ educational practice influence their clinical work? 3. What are the social contexts for GP trainers’ clinical and educational practice? These questions are addressed within a pragmatic theoretical framework to build up an ethnographic description of the participants’ experiences. Data collection is through semi-structured interviews and observation of video-recorded teaching. Ethical issues associated with the study are discussed in detail, in particular the challenges of “insider” research. Four approaches are used for data analysis: global impressions; word cloud analysis; thematic analysis; and analysis shaped by AT. In answer to RQs 1 and 2, the study finds that GP trainers experience their dual roles as intimately linked, intuitively transferring their skills between their clinical and educational practice. The study also finds that GP trainers reconstruct their professional identities through teaching. With regard to RQ 3, engaging in teaching can lead to internal conflict for GP trainers and tensions with their colleagues, trainees and regulators. These findings are discussed in relation to medical education research methodology and the impact the study on the researcher is explored. The thesis closes by considering the conflicted position the participants occupy, concluding that teaching offers physicians the opportunity to reconstruct their professional identities so they can approach tensions in their practice with a sense of agency and optimism.

O objetivo do trabalho foi avaliar o funcionamento dos Serviços de Medicina do Trabalho das empresas localizadas nos Municípios da Grande São Paulo. Para tanto foi preparado um questionário contendo questões pontuadas estruturadas com base, principalmente, no recomendado pela Convenção 161 da Organização Internacional do Trabalho. Foi sorteada uma amostra estratificada de 109 empresas de uma relação que continha 1.918. Esta relação, o Universo foi construída a partir de dois cadastros. O primeiro fornecido pela Delegacia Regional do Trabalho de São Paulo DRT -SP e o segundo a partir dos dados registrados pelo Instituto Brasileiro de Geografia e Estatística - IBGE no Censo de 1985. O Serviço de Medicina do Trabalho de cada empresa foi avaliado em relação a 5 itens: funções, organização, condições de funcionamento, exame médico e local onde está instalado. Estes foram subdivididos sendo que ao final cada empresa foi avaliada segundo 64 sub-itens. Cada subitem recebeu uma pontuação que variou entre O e 4,75. A empresa que realizasse todas as atividades previstas no questionário, da forma como se esperava ao construi-lo poderia atingir o valor máximo de 104,5 pontos. As 109 empresas da amostra empregavam cerca de 145.000 trabalhadores. A pontuação média atribuída ao conjunto das empresas foi 71,08. Por representar este valor 67,70% do valor máximo que seria possível, foi considerado baixo. Foram comparadas as empresas por meio das pontuações atribuídas em relação aos vários estratos representados, isto é número de empregados, município onde se localizavam e ramo de atividade. Duas terças partes das empresas da amostra pertenceram ao ramo de atividade industrial, e uma terça parte a outros ramos de atividade. As empresas industriais atingiram valor mais elevado do que as empresas ligadas a outros ramos de atividade. Não foi observada diferença entre os valores atribuídos a empresas sediadas na Capital e as localizadas em outros Municípios. Também não foi observada diferença entre os valores atribuídos a empresas e número de empregados de forma isolada. Todavia quando houve associação entre número de empregados e ramo de atividade verificou-se que as empresas ligadas a ramos de atividades diferente do industrial, e de mais de 1000 empregados, foram aquelas que receberam pontuação mais baixa. O item que se refere a exames médicos recebeu em média uma pontuação mais próxima do máximo possível para o item e o que se refere a funções a mais distante. Em relação aos sub-itens do item funções foi observado que a pontuação mais elevada foi verificada em relação a análise dos acidentes de trabalho e doenças ocupacionais, à identificação dos riscos, a readaptação de trabalhadores em outras funções e nas atividades de vigilância dos locais de trabalho. As pontuações mais baixas foram atribuídas às atividades educativas dirigidas para os trabalhadores, ao registro de acidentes de trabalho e doenças profissionais, e na prestação de assessoria técnica pelo Médico do Trabalho à empresa e ao Sindicato de Trabalhadores. As informações levantadas em relação ao item organização mostraram que os sindicatos de trabalhadores ligados às indústrias têm obtido com frequência, nos dissídios coletivos das respectivas categorias, cláusulas que facilitam a ação sindical nas empresas quando ocorrem acidentes de trabalho e doenças profissionais. Quanto às condições de funcionamento, ficou bem caracterizada a deficiente comunicação entre os sindicatos de trabalhadores e os Serviços de Medicina do Trabalho das empresas o que significa que freqüentemente os trabalhadores deixam de receber informações sobre os riscos da ocupação. Também ficou bem caracterizado que os Serviços de Medicina do trabalho das empresas não estão sendo informados pelo empregador ou encarregados, sobre fatores que possam afetar a saúde dos trabalhadores. Em relação ao item Exames Médicos, o conjunto das empresas obteve pontuação elevada, porque a maior parte delas está realizando os exames exigidos pela legislação como estabelecido. Em relação a instalações e facilidades para transporte de pacientes em situações de emergência a pontuação foi baixa porque uma parte das empresas tinha área física menor que 1O metros quadrados para cada 100 empregados por turno e também porque grande parte delas não tinha viatura ou outro meio apropriado para transportar, de forma adequada, paciente em estado grave. Houve melhora dos Serviços Médicos de Empresas Industriais em relação à estudo realizado por Nogueira em 1967. Assim, em relação às industrias, melhoraram as instalações, os exames pré-admissionais e periódicos são realizados em maior número de empresas, as atividades educativas são mais freqüentes e há contratação de mais pessoal auxiliar como por exemplo os auxiliares de enfermagem do trabalho. As empresas ligadas a outros ramos de atividade estão pior estruturadas. Estas têm atualmente uma qualificação semelhante aquela que foi observada por Nogueira nas indústrias em 1967. / The present study was done with the objective of evaluating the operation of medical services in enterprises located in cities belonging to Greater Sao Paulo. A questionnaire composed of items based mainly in the International Labour Organisation Convention 161 was applied. A certain number of points was attributed to each question. A stratified sample composed of 109 enterprises was drawn by choice from a list of 1918 units. This list represented the universe, derived from two rosters. One had been provided by the Regional Delegation of Labour in the State of Sao Paulo, and the other contained data registered by the Brazilian Institute of Geography and Statistics - IBGE - according to the 1985 census. The medical service in each plant or undertaking was evaluated according to tive items: functions, organization, operating conditions, medical examinations and local where the service is situated. These items were divided so that the evaluation for each enterprise ended with 64 sub-items. Each sub-item received a number of points varying from O until 4.75. An enterprise accomplishing all the activities contemplated in the questionnaire, the way it was expected when it was devised, could reach 104.5 points as a maximum value. Approximately 145000 workers were employed by all 109 enterprises. The average number of points attributed to all enterprises as an overall evaluation was 71.08. This was considered as a low figure, since it represents 67.07% of the maximum possible value. The number of points was used to compare the enterprises stratified according to number of workers, city where the enterprise is located and branch of activity. Two thirds of enterprises in the sample belong to industrial branches of activity, and one third to other branches. Industrial plants reached values higher than other branches of activity. No difference was observed between values assigned to enterprises situated in São Paulo proper, the Capital of the State, and those located in other cities. Neither was there a difference between values assigned to enterprises and the number of workers \"per se\". However, when number of workers and branches of activity were associated, it was observed that enterprises belonging to branches other industries, hiring over 1000 workers had a smaller number of points. The average number of points closest to the maximum possible refers to medical examinations, and the farthest corresponds to functions. Examination of sub-items in the function item indicates the highest number of points for the analysis of occupational accidents and diseases, risk identification, rehabilitation of workers in different

O objetivo do trabalho foi avaliar o funcionamento dos Serviços de Medicina do Trabalho das empresas localizadas nos Municípios da Grande São Paulo. Para tanto foi preparado um questionário contendo questões pontuadas estruturadas com base, principalmente, no recomendado pela Convenção 161 da Organização Internacional do Trabalho. Foi sorteada uma amostra estratificada de 109 empresas de uma relação que continha 1.918. Esta relação, o Universo foi construída a partir de dois cadastros. O primeiro fornecido pela Delegacia Regional do Trabalho de São Paulo DRT -SP e o segundo a partir dos dados registrados pelo Instituto Brasileiro de Geografia e Estatística - IBGE no Censo de 1985. O Serviço de Medicina do Trabalho de cada empresa foi avaliado em relação a 5 itens: funções, organização, condições de funcionamento, exame médico e local onde está instalado. Estes foram subdivididos sendo que ao final cada empresa foi avaliada segundo 64 sub-itens. Cada subitem recebeu uma pontuação que variou entre O e 4,75. A empresa que realizasse todas as atividades previstas no questionário, da forma como se esperava ao construi-lo poderia atingir o valor máximo de 104,5 pontos. As 109 empresas da amostra empregavam cerca de 145.000 trabalhadores. A pontuação média atribuída ao conjunto das empresas foi 71,08. Por representar este valor 67,70% do valor máximo que seria possível, foi considerado baixo. Foram comparadas as empresas por meio das pontuações atribuídas em relação aos vários estratos representados, isto é número de empregados, município onde se localizavam e ramo de atividade. Duas terças partes das empresas da amostra pertenceram ao ramo de atividade industrial, e uma terça parte a outros ramos de atividade. As empresas industriais atingiram valor mais elevado do que as empresas ligadas a outros ramos de atividade. Não foi observada diferença entre os valores atribuídos a empresas sediadas na Capital e as localizadas em outros Municípios. Também não foi observada diferença entre os valores atribuídos a empresas e número de empregados de forma isolada. Todavia quando houve associação entre número de empregados e ramo de atividade verificou-se que as empresas ligadas a ramos de atividades diferente do industrial, e de mais de 1000 empregados, foram aquelas que receberam pontuação mais baixa. O item que se refere a exames médicos recebeu em média uma pontuação mais próxima do máximo possível para o item e o que se refere a funções a mais distante. Em relação aos sub-itens do item funções foi observado que a pontuação mais elevada foi verificada em relação a análise dos acidentes de trabalho e doenças ocupacionais, à identificação dos riscos, a readaptação de trabalhadores em outras funções e nas atividades de vigilância dos locais de trabalho. As pontuações mais baixas foram atribuídas às atividades educativas dirigidas para os trabalhadores, ao registro de acidentes de trabalho e doenças profissionais, e na prestação de assessoria técnica pelo Médico do Trabalho à empresa e ao Sindicato de Trabalhadores. As informações levantadas em relação ao item organização mostraram que os sindicatos de trabalhadores ligados às indústrias têm obtido com frequência, nos dissídios coletivos das respectivas categorias, cláusulas que facilitam a ação sindical nas empresas quando ocorrem acidentes de trabalho e doenças profissionais. Quanto às condições de funcionamento, ficou bem caracterizada a deficiente comunicação entre os sindicatos de trabalhadores e os Serviços de Medicina do Trabalho das empresas o que significa que freqüentemente os trabalhadores deixam de receber informações sobre os riscos da ocupação. Também ficou bem caracterizado que os Serviços de Medicina do trabalho das empresas não estão sendo informados pelo empregador ou encarregados, sobre fatores que possam afetar a saúde dos trabalhadores. Em relação ao item Exames Médicos, o conjunto das empresas obteve pontuação elevada, porque a maior parte delas está realizando os exames exigidos pela legislação como estabelecido. Em relação a instalações e facilidades para transporte de pacientes em situações de emergência a pontuação foi baixa porque uma parte das empresas tinha área física menor que 1O metros quadrados para cada 100 empregados por turno e também porque grande parte delas não tinha viatura ou outro meio apropriado para transportar, de forma adequada, paciente em estado grave. Houve melhora dos Serviços Médicos de Empresas Industriais em relação à estudo realizado por Nogueira em 1967. Assim, em relação às industrias, melhoraram as instalações, os exames pré-admissionais e periódicos são realizados em maior número de empresas, as atividades educativas são mais freqüentes e há contratação de mais pessoal auxiliar como por exemplo os auxiliares de enfermagem do trabalho. As empresas ligadas a outros ramos de atividade estão pior estruturadas. Estas têm atualmente uma qualificação semelhante aquela que foi observada por Nogueira nas indústrias em 1967. / The present study was done with the objective of evaluating the operation of medical services in enterprises located in cities belonging to Greater Sao Paulo. A questionnaire composed of items based mainly in the International Labour Organisation Convention 161 was applied. A certain number of points was attributed to each question. A stratified sample composed of 109 enterprises was drawn by choice from a list of 1918 units. This list represented the universe, derived from two rosters. One had been provided by the Regional Delegation of Labour in the State of Sao Paulo, and the other contained data registered by the Brazilian Institute of Geography and Statistics - IBGE - according to the 1985 census. The medical service in each plant or undertaking was evaluated according to tive items: functions, organization, operating conditions, medical examinations and local where the service is situated. These items were divided so that the evaluation for each enterprise ended with 64 sub-items. Each sub-item received a number of points varying from O until 4.75. An enterprise accomplishing all the activities contemplated in the questionnaire, the way it was expected when it was devised, could reach 104.5 points as a maximum value. Approximately 145000 workers were employed by all 109 enterprises. The average number of points attributed to all enterprises as an overall evaluation was 71.08. This was considered as a low figure, since it represents 67.07% of the maximum possible value. The number of points was used to compare the enterprises stratified according to number of workers, city where the enterprise is located and branch of activity. Two thirds of enterprises in the sample belong to industrial branches of activity, and one third to other branches. Industrial plants reached values higher than other branches of activity. No difference was observed between values assigned to enterprises situated in São Paulo proper, the Capital of the State, and those located in other cities. Neither was there a difference between values assigned to enterprises and the number of workers \"per se\". However, when number of workers and branches of activity were associated, it was observed that enterprises belonging to branches other industries, hiring over 1000 workers had a smaller number of points. The average number of points closest to the maximum possible refers to medical examinations, and the farthest corresponds to functions. Examination of sub-items in the function item indicates the highest number of points for the analysis of occupational accidents and diseases, risk identification, rehabilitation of workers in different

This research used a case study approach to chronicle the process of seeking the American Nurse Credentialing Center's Pathway to Excellence in Long-Term Care designation in one Midwest community. The PTE-LTC practice standards framework guided the implementation of professional nursing practice which focused on a positive practice environment, shared decision-making, accountability for resident care, and the leadership development of nursing staff. These practice standards are outlined in the study and incorporated the major components necessary to implement Professional Nursing Practice and Shared Governance in long-term care. The components of the designation process over a five-year period were documented and compared with other models of shared governance and professional practice supported in the literature. The study included a rich description of the structures and processes in place prior to the designation process and those developed during the process to operationalize the model. The methods which were used to accomplish these organizational changes are identified as well. In addition, the study reports on the effects of the model implementation on organizational, nursing, and resident measures. The implementation of, and support for, a professional nursing practice role and environment in a nursing home was expected to improve both the quality of care and quality of life for older adults who live in the nursing home, as well as staff job satisfaction and retention of nursing staff.

Three-dimensional appearance models represent an essential outcome of industrial design practice, facilitating the origination, evaluation and specification of exterior form. As manufacturers face increasing pressure to reduce time scales for new product development, the production of such models using conventional fabrication techniques must be appraised. As a means of economically translating digital geometry into one-off components, rapid prototyping has the potential to contribute towards a reduction in lead times for the production of appearance models. The objective of this research is to propose a methodological approach for the effective integration of rapid prototyping within industrial design practice. The field and practice of industrial design is defined, the technology of rapid prototyping discussed, and their integration proposed through a draft computer-aided industrial design/rapid prototyping (CAID/RP) methodological approach. This is exposed to practitioner feedback, modified, and employed as a revised CAID/RP methodological approach during the industrial design of a nylon line trimmer. The product outcome is used to compare and contrast the production of an appearance model via rapid prototyping, an appearance prototype via rapid prototyping, and an appearance model via conventional fabrication techniques. Two issues arise from the use of the revised CAID/RP methodological approach: the production of stl files and the lack of physical interaction with product form. In addition, the emergence of rapid prototype sketch modelling systems following the line trimmer case study provides an opportunity for further enhancement. A strategy for the resolution of these issues is proposed, and their effectiveness evaluated through additional case studies. The resulting CAID/RP methodological approach is subject to validation through practitioner interviews and a normalised rating/weighting method. The positive feedback acknowledges the significance of the CAID/RP methodological approach through a reduction in product development lead times and enhancement of professional practice. The project makes a contribution to new knowledge and understanding in the area of professional practice through the definition and validation of operational paradigmatic change.