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The role of teacher leaders in schools is becoming more prevalent as educators examine ways to insure systemic change. It is based on the assumption that education will improve when those closest to the situation are included and encouraged to not only participate in the decision-making process, but also to initiate change. The purpose of this study was to describe the principals' support of teacher leaders in elementary schools in one school system. This study collected data from all public elementary school principals in a large suburban school district in Virginia and from selected elementary level teachers in order to answer the following four research questions: 1. Do elementary principals and/or teachers perceive they support the development of teacher leaders? 2. Do elementary principals and/or teachers perceive teacher leaders serve as a vehicle for shared decision-making? 3. Do elementary principals and/or teachers perceive teacher leaders as instrumental in expanding the focus of shared decision-making to include instructional decisions? 4. Do teachers and/or principals receive preparation at the college/university level to assume teacher leadership positions or as principals to guide teachers to assume leadership positions? The findings of this study indicated that elementary principals and teacher leaders perceive there is support for teacher leaders in their school. There is also agreement that teachers should participate in shared decision-making structures. There is disagreement between the two groups as to the level of participation in such areas as finances, personnel and implementation of new school programs. Finally, the principals do not believe that course work at the university/college level assisted them in promoting and supporting teacher leadership in their school. / Ed. D.

This dissertation, and its companion dissertation, are the products of a collaborative research project that was conducted by two doctoral students. The process utilized is discussed. The research project focused on site-based management and shared decision-making. Site-based management (SBM) is a strategy that involves the decentralization of authority, and shared decision-making (SOM) among those involved. H is based on the assumption that education will improve when those closest to the situation are included in the decision-making process, and held accountable for their decisions. This study describes the status of SBM/SOM in the public secondary schools of Virginia in regards to teacher and principal participation, size of secondary school, and geographic location. / Ed. D.

The purpose of this study was twofold: to examine (1) how shared decision making was operating in a large urban high school, especially in the administrative areas of personnel, finance, staff development and curriculum and instruction and (2) why shared decision making was operating in the manner it was. A descriptive case study was conducted of the school’s organizational and administrative processes to determine staff involvement in decision making. Four central office department heads, two assistant principals, four department chairpersons, six teachers, four Faculty Council members, and four parent members of the Planning Council were interviewed to determine perceptions of shared decision making at the subject school. Data gathered from the different stakeholders were transcribed from tape recordings and entered into participant-by-involvement matrices. School documents were reviewed, and data retrieved were entered into documents used as sources of data matrix. The participant-by-involvement matrices and documents used as sources of data matrix were then stacked comparing involvement of stakeholders in the administrative areas of personnel, finance, staff development, and curriculum and instruction. Data emerged from these stacked matrices which provided the findings from which conclusions were drawn. The data indicated that there was no model for shared decision making in operation within the school system or at the school level. Disjointed activities and responsibilities in the guise of shared decision making were parcelled out by the division superintendent to the schools to be implemented. Opportunities for stakeholder participation were better organized and managed in the areas of staff development and curriculum and instruction. However, the same was not true in personnel and finance, as activities were isolated and disjointed; and stakeholder involvement was selective rather than inclusive. The reason shared decision making activities were better organized and managed in the areas of staff development and curriculum and instruction was the superintendent mandated stakeholder participation in the two areas and the building principal extended the mandate to the school. While there was no mandate to include stakeholders in personnel and financial decisions, the building principal attempted to include selected stakeholders in isolated activities. / Ed. D.

This research study is based on the cluster system model for effective management of schools in Namibia. with special reference to Erongo Education Region. The cluster system introduces a new perspective on the way the schools arc managed. It radically differs from the historically isolated school, employing individualistic approaches and management practices characterised by strong hierarchical structures and top down decision-making. The cluster system advocates shared decision-making, teamwork, collaboration. integration and networking. In other words clustering provides a superb climate for teachers, principals, parents and learners to interface with one another within a legitimate framework. Clustering is an effective management model that has also been implemented in developed countries such as England, the Netherlands and the United States of America. The research study involved 60 principals as respondents to a questionnaire on the cluster system, its problems and prospects. The major findings indicate that clustering enhances the quality of education through sharing of resources, exchange of ideas among teachers, and closer cooperation between schools. The study identifies numerous challenges in the implementation of the cluster system. These challenges include disparity between schools in the rural and urban areas, lack of reliable transport, lack of facilities and teaching materials in most schools, large distances between schools, teacher isolation and increased workload among personnel. However, if the challenges and prospects of clustering are put on a simple scale, the latter would probably outweigh the former completely. This means that clustering holds encouraging prospects for the education system in Namibia in general and Erongo Education Region in particular. An important finding in this regard is that the majority of the principals in the Erongo Education Region agree that the cluster system has the potential to champion and transcend in effective management of all schools within cluster centres. / Thesis (M.Ed.)--North-West University, Potchefstroom Campus, 2006.

Pediatric medicine, the branch of medicine dedicated to taking care of children, is a relatively new medical specialty, developing in the mid-19th century. Pediatrics emerged as society began to believe that children were different from adults and in need of specialized care. Soon after the development of specialty medicine for children it became evident that many challenging ethical issues were present with children that did not exist, or at least not to the same extent with adults. In some cases, issues are similar, however they become much more complex or challenging when applied to children. The field of pediatrics is constantly changing and developing, with tremendous advancements within the fields of genetics, neuroscience, and clinical research. Developments in these fields have led to the emergence of many new diagnostic and therapeutic interventions for children, but with these new technologies come enhanced ethical issues and challenging decisions. Currently within pediatric medicine, decision-making processes are primarily guided by the models of adult surrogate decision making, in particular substituted judgment and best interests models. The substituted judgment model focuses on executing the wishes of the patient, while best interests asks the surrogate to select the course of action that will most benefit the patient overall. These models are ethically contested within adult medicine, the field in which they originated, and are even more problematic when applied to children, specifically mature minors with varying developmental levels. In pediatrics, the best interests standard is the typical model advocated for because children, as children, cannot legally make their own decisions, however that does not mean they should be automatically excluded from decision making processes or assumed to lack decision making capacity. These issues become larger when dealing with mature minors due to issues of agency, consent and assent, stewardship, and the vulnerable status of the child. Children are not only viewed as vulnerable by society, but many times parents as well. Many parents feel it is their obligation and duty to not only take care of their children but also advocate for and protect them. Additionally, because they are so emotionally invested and connected to the child, it is difficult to comprehend situations where the child is at risk or they are told something they never imagined or thought about, such as that their child is very sick and in need of advanced medical care. There are heightened emotions present due to the parent-child relationship. Despite parents wanting to protect their children, in most medical instances they are unable to do so, leaving parents vulnerable and full of emotion. Making decisions for another is very challenging in all instances throughout medicine, complicated even more so when the person for whom decisions are being made is a relative and a person that one strives to protect and take care of on a day to day basis. Additionally in pediatrics many decisions have higher stakes and longer impacts, due to the age, status, and development of the child. Parents are in very challenging positions when making decisions for their children in light of the tremendous amounts of uncertainty that accompany new and emerging technologies, including obstacles that make determining the child’s best interests and inevitably make a decision challenging. The addition of complicated medical information from presented by the new technologies within the fields of genetics, neuroscience, and clinical research, combined with the and heightened emotions only complicates this process, necessitating an enhanced decision making model. <br>As in areas of adult medicine, decisions are challenging and difficult to work through, complicated more by the lacking of explicit goals of pediatric medicine and an overarching framework to use to structure all decision making processes, which exists in adult medicine. The current decision-making models do not accommodate the fact that within pediatrics there is a long term relationship and partnership that must be created and nurtured by all those involved; decisions are therefore not isolated decisions but components of a continuum. Additionally, they do not ensure that parents receive support and guidance, identify the level of involvement of an older child, or facilitate and assist with decisions when parents and physicians disagree. Along with some of the objective elements of medicine, pediatric decision making has many subjective components, and emerging technologies create even more. On the basis of these considerations, it is argued that there is a need for an enhanced decision making model developed out of the field of pediatrics, centered around the goals of pediatric medicine. Current models need to be reconsidered in order to outline a model that enables parents to make the optimal decision for their child in light of the possibilities of emerging technologies. <br>This dissertation will look at the question “Why should an enhanced model for parental decision making be advocated for within pediatric care, and how can such a model be developed and applied?” In Chapter 2 the history and development of the field of pediatrics will be looked at, followed by an analysis of the current decision making models of adult medicine in Chapter 3, demonstrating that they do not apply well to mature minors and are not sufficient for pediatric medicine. In Chapter 4 the changing field of pediatric medicine will be explained, the new technologies will be introduced, and the ethical issues that the current models of decision making do not accommodate will be presented. In Chapter 5, an enhanced model of shared decision making related to the goals of pediatric medicine will be developed followed by an analysis of the roles of parties involved and how they should work together to achieve the best results for the child who is the patient. In chapter 6 the enhanced decision making model will be applied to areas of genetic screening, neuroscience, and clinical research to show how it will better facilitate decisions within these areas and address the concerns that the new technologies and developments create throughout present-day pediatrics. Pediatric medicine is in great need of an enhanced parental decision-making model that addresses the goals of pediatric medicine to ensure that the best decisions are made in the face of new technologies and the continuous advancement of care for children. / McAnulty College and Graduate School of Liberal Arts; / Health Care Ethics / PhD; / Dissertation;

Decisions concerning psychiatric medication are complex and often involve a protracted process of trial and error. The serious and enduring nature of side effects associated with psychiatric medication demands that medical and experiential expertise is shared in a way that is supportive of the longer term recovery journey. Historically poor concordance rates point to a lack of trust and difficulties in sharing decisions constructively. This Ph.D. explores views and experiences of shared decision making for psychiatric medication management amongst mental health service users and practitioners. The study was conducted in a community mental health service, in the UK. A participatory methodology was employed, within a social constructionist paradigm. Service users and a carer were involved in all phases of the research process. Thirty qualitative interviews were undertaken with different stakeholders: psychiatrists, community psychiatric nurses, and service users. A thematic analysis was employed. In addition, an applied conversation analysis was undertaken on four recorded outpatient medication related meetings. Enablers of and barriers to shared decision making were found at three levels of analysis: the interaction, the relationship, and the system. Many divergent discourses were apparent across these levels, both within and between the different stakeholder groups. A typology of involvement is proposed and discussed, from fractured passivity through to active self- management. The barriers to collaborative practice identified in these findings, and the structural factors at work in the mental health system in particular, were seen to explain the gap between policy ideals and current practice. Strong therapeutic relationships were found to be a vital enabler, comprising of: a formation of trust, practitioners knowing and believing in service users’ potential, and ‘walking the journey together’. Shared decision making in this study is found to be a dynamic process over time, involving two (or more) participants in a complex interplay. The thesis emphasizes the interaction between structure and agency in shared decision making in psychiatric medication management and highlights how power is enacted in the context of shared decisions in a community setting. Original theoretical, methodological and practical contributions to knowledge are presented and discussed.

Purposes/Aims: The aim of this study was to create a web-based brokerage of patient decision-making aids, titled Split Decision™, and to evaluate student nurse and student nurse practitioners' intent to use and recommend the prototype website based on their perceived usability, usefulness and satisfaction. Rationale/Background: Adult patients frequently report confusion about treatment options, hindering their ability to fully participate in healthcare decision-making. Over 500 patient decision-aids exist on the internet, but are scattered across dozens of websites. Creation of a web-based decision-aid platform would utilize the existing information-seeking habits of patients, but provide them with evidence-based information when evaluating treatment options. Methods: Exemplar decision-aids were chosen from the 563 decision-aids published in the Ottawa Research Institute database and posted on a decision-aid brokerage website. Online access to the website was offered to study participants (n=29) from May to June 2016. Demographic information, quantitative and qualitative responses were collected from each website user and analyzed to evaluate perceived usability, satisfaction, and intention to use the pilot website. Results: Usability of the Split Decision™ website was found to be above average on Systems Usability Scale ratings. Participants rated the website highest on visual appeal and clear terminology on quantitative measures. Qualitative responses cited confusion with the navigation of pages and hyperlinks as areas of future improvement. Conclusion: Study participants expressed a hope for future expansion of the website to other topics and patient populations. Further study of the Split Decision™ website will be planned to test revisions suggested during by participants during this doctoral project.

Introduction: Shared decision making (SDM) has been advocated as an optimal approach to medical decision-making. Yet, little is known about how patients perceive SDM and whether patient-defined SDM is associated with patient outcomes. Methods: This three-manuscript dissertation used a mixed-methods approach including a systematic literature review and both qualitative and quantitative research methods. The aims were to: (1) systematically review the patient outcomes studied in relation to SDM and identify under what measurement contexts SDM is associated with which types of patient outcomes; (2) use in-depth, qualitative interviews to develop a conceptual model of patient-defined SDM and compare this to recent decisions that patients labeled as shared; and (3) apply the model of patient-defined SDM to the context of colorectal cancer screening. Results: Study 1 found that 39 studies measured SDM and evaluated it with a patient outcome, and only 43% of patient outcomes assessed were significantly associated with SDM. Patient reports of SDM were most likely to be associated with outcomes. Study 2 found that patients’ conceptual definition of SDM included four components: exchange of information, active listening, patient-self advocacy, and a personalized physician recommendation. Patient descriptions of recent decisions labeled as shared ranged from very simple recommendations through complex interactions, with the only commonality among shared decisions being that the patient and physician ultimately agreed. Study 3 found that the most commonly observed component of patient-defined SDM was patient self-advocacy (76%) and least common was a personalized physician recommendation (23%). Only 9% visits contained all four patient-defined SDM components. In adjusted models, physician provision of information around the process and potential side effects of colorectal cancer screening was associated with an increase in screening. There were differences in screening rates by the patient’s initial verbal response to the physician recommendation with those who initially refused being least likely to be screened (40%) and patients who did not verbalize a response to the recommendation being most likely to be screened (70%). Discussion: Findings across the three studies highlight the complexity of studying and measuring SDM and emphasize the importance of the patient’s perspective on SDM.

This thesis investigated how clients and therapists discuss the means by which clients can work towards their therapeutic goals. Cooper et al. (2016) termed such discussions meta-therapeutic communication or meta-therapeutic dialogue and Cooper and McLeod (2011) recommend carrying them out since outcomes are robustly related to whether the client accepts the therapeutic strategy as appropriate for their needs (e.g. Horvath et al., 2011). This thesis undertook the first discovery-oriented, Conversation Analysis (CA) study of how clients and therpaists actually carry out meta-therapeutic discussions. It represents a sustained attempt to bridge the practice-research gap and highlights the conceptual and practical challenges in doing so. 42 audio-recorded pluralistic therapy sessions were sampled across seven therapist-client pairs. Before carrying out the CA study proper, it was necessary to conceptually link broad descriptions of meta-therapeutic dialogue to participants’ concrete actions in therapy sessions. This involved a review of related concepts (Chapter Two), as well as a detailed conceptualization of how therapists’ stocks of interactional knowledge (SIKs) (Peräkylä & Vehviläinen, 2003) regarding meta-therapeutic dialogue might demonstrably link with their concrete actions as described by CA findings (Chapters Three through Five). Therapists’ questions to clients about what might be helpful were selected as a likely site for meta-therapeutic dialogue and were subjected to an in-depth CA investigation of the practical issues participants themselves treated as important in their interactions around these questions (Chapters Six through Eight). Findings show how some apparent opportunities for meta-therapeutic dialogue are less facilitative of clients’ independent input, and can sometimes be interactionally coercive. There is evidence that facilitating dialogical opportunities for talking about what might be helpful may require the therapist to move back-and-forth between opposing positions, such as treating the client as potentially unknowing but still also holding open a space for their contribution. These findings extend existing SIKs regarding meta-therapeutic dialogue by specifying some concrete considerations therapists orient to during such endeavours. Some practical similarities between meta-therapeutic dialogue and problem-solving/solution-focused approaches are also highlighted.