The No Child Left Behind Act of 2001 and the accountability movement that has engulfed education in the last 20 years have put leadership at the heart of school improvement. Student achievement is affected by multiple factors that must be addressed with unique leadership skills and specialized knowledge. No one person can be responsible for orchestrating the success of each student within a school building. When members of a school community share responsibility for the many activities that contribute to student learning, the work of educational leaders becomes a manageable task. The purpose of this study was to create an operational definition of shared leadership by identifying key descriptors that define the characteristics and behaviors of shared leadership and the aspects of school cultures in which it can be effective. The procedure used to construct a rich description of shared leadership was a three-round Delphi study. A panel of experts was assembled from writers or researchers in the field of leadership and superintendents, principals, and teachers who have practiced shared leadership in the school environment. The first-round Delphi instrument consisted of four open-end questions that asked for key words or phrases that describe the characteristics and behaviors of shared leadership, key words or phrases that describe aspects of school cultures in which shared leadership can be effective, and key words or phrases that describe barriers to shared leadership. In the second round, panelists were asked to rate the compiled responses from round one on a four-point scale. In the third round, panelists received statistical information based on second-round responses. They were allowed to revise opinions once more using a four-point scale. Using the Delphi technique, the panel of experts reached consensus on 84 critical elements of effective shared leadership. An inventory that can be used by schools as a guide for planning, implementing, and evaluating shared leadership in school settings was created from the data. / Ed. D.

Colorectal cancer (CRC) screening in the form of self-sampling enhances participation and early cancer detection. However, CRC screening participation in Sweden is marked by inequality. Moreover, individuals are relatively uninformed about screening procedures, with existing informational channels all exhibiting various limitations. Hence, this project was initiated in collaboration with KI and KTH to develop a digital decision aid for individuals called into CRC screening. This study aims to mark an initial stage of development, with the overarching goal being to improve CRC screening participation rates and support informed decision making aligned with patient values and preferences. Using an approach rooted in the shared decision-making (SDM) model, the study investigates user attitudes and preferences concerning health, digital healthcare services and cancer screening through conducting semi-structured interviews and a thematic analysis. These insights inform user requirements, which are integrated with stakeholder requirements and the current informational landscape to shape the digital decision aid’s information architecture and design. The research identifies various challenges and opportunities for the development of the digital decision aid in a Swedish context, underscoring the importance of adapting the decision aid to user needs and preferences. In subsequent stages of development, the prototype produced by this study should be evaluated through usability testing, and further user research should be conducted to generate more specific user requirements concerning visual and interactional elements.

Implementation and uptake of novel and cost-effective medicines can improve patient health outcomes and healthcare efficiency. However, the relative uptake of new medicines recommended by the National Institute for Health and Care Excellence often lags behind other comparative countries’ health systems. One example is the uptake of direct oral anticoagulants (DOACs) for stroke prevention in atrial fibrillation, which was slow and had a high level of unexplained variation across different health economies in England. This research aimed to explore barriers and enablers to the uptake of DOACs from the perspectives of patients, healthcare professionals, and key stakeholders by conducting systematic and narrative reviews and semi-structured interviews. Data collected from 21 patients, 23 healthcare professionals, and 23 key stakeholders recruited from three different health economies was analysed using the Framework method. The findings identified a range of intersecting factors acting as barriers and/or enablers to the uptake DOACs. While there were a wide range of experiences and views, an agreement between patients and healthcare professionals/key stakeholders on several identified factors was observed. Attributes of the innovation, characteristics of patients and prescribers, local health economy readiness for change, implementation process, and external health system context were suggested as influences. Mapping of the findings to the Diffusion of Innovations in Service Organisations model identified 11 components for a future toolkit development to facilitate uptake of nationally recommended new medicines. This thesis highlighted the role of patients, consideration of all costs associated with new medicines, and compatibility with the health economy’s care model impact on the uptake.

Compared to the general population, socially disadvantaged patients have higher rates of chronic illness and require more complex medical care. They also endorse higher levels of psychological distress and tend to engage in behavioral risk factors such as poor diet, physical inactivity, and smoking. These issues are particularly concerning given that this population tends to adhere less to medical recommendations, has limited access to health resources, and receives poorer treatment from providers. In an effort to address this disparity, The Affordable Care Act will expand health care access to an additional 23 million uninsured and 17 million underinsured Americans. However, simply expanding access to health care without examining and improving upon factors related to the physician-patient relationship would not fully address the health care needs of this population. This study sought to improve the quality of care received by socially disadvantaged patients by better understanding the role of race and gender on the physician-patient communication process and patient outcomes in a safety net primary care clinic. The study sample consisted of 330 low-income, uninsured/underinsured African American and White patients and 41 resident physicians. Overall, African American patients and their doctors and White doctors and their patients were viewed as engaging in the highest levels of communication. South Asian physicians, and male South Asian physicians in particular, had the lowest levels of communication and the patients of these providers experienced less improvement in their physical health. Patient education level influenced physicians’ perceptions of their patients to the extent that patients with higher educational levels were viewed as engaging in lower levels of communication. Last, indicators of a good physician-patient relationship were associated with higher levels of patient reported adherence. Practice implications and areas for future research are discussed.

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Health care reform has caused consumers to learn more about what it means to have health insurance and its costs. Patient engagement, a critical component of health care reform, reflects provider and consumer attention to shared decision making between patient and physician. The problem addressed in this study is that although researchers have studied patient engagement, there has been insufficient exploration of the relationship between financial literacy and patient engagement, which could negatively impact health outcomes not only for patients or consumers but for society as a whole. The purpose of this quantitative research was to determine if a relationship exists between patient financial literacy and patient engagement, as measured by the patient activation measure. The potential effects of increased patient financial responsibility due to high deductible health plans, measured via an item inquiring about participants' deductible, as well as shared decision making between physician and patient were also evaluated as potential moderators between financial literacy and patient engagement. Theories used to provide conceptual context include Shim's cultural health capital theory and Bourbeau's (2008) self-management model. Two hierarchical linear multiple regression models were used to test the research hypotheses. While the research did not find a significant relationship between patient financial literacy and patient engagement, it did confirm the importance of mental health status and patient-physician shared decision making as important predictors of patient engagement. These findings provide a better understanding of financial literacy and specific financial behaviors in the context of healthcare environment today.

The historical perspective of schools in our democratic society provides a framework of tension between local parent and community control and professional and state control of public school decisions. Today, federal and state requirements demand increased student achievement. One school reform effort enlisted to help meet the challenges is the creation of site-based decision-making councils that involve school administrators, teachers and parents. The state of Utah requires each public school to have a School Community Council that is responsible for the development of plans for school improvement. Limited funds are provided to each School Community Council through the School LAND Trust Program. The funds are to be used to assist in the implementation of the developed plans for the purpose of increased student achievement. Three Utah Middle level SCCs participated in this qualitative strength-based process evaluation. Two of the SCCs were identified as exemplary, and the third SCC was just beginning to function as an SCC. Based on the three questions guiding the evaluation, the evaluation learned that SCCs identified as exemplary were compliant with the law, employed strategies identified in the literature for effective site-based decision-making, and implemented plans that were perceived to impact student achievement. In addition, themes emerged from the strength-based approach to learn what SCC processes influenced an effective balance between the professional expertise and the democratic involvement in decision-making. The emergent themes deal with processes related to membership and elections, sources of confidence, use of data to drive school improvement decision, and communication.

Purpose. To systematically develop and field test an intervention to engage families and healthcare teams in the decision-making process about life support for critically ill patients in the Intensive Care Unit (ICU). Setting. Adult medical-surgical ICU at a Canadian academic teaching hospital. Methods. The International Patient Decision Aid Standards (IPDAS) criteria and the Interprofessional Shared Decision Making (SDM) model guided the study of families facing decisions about life support for their relative in ICU that involved:1) systematic review; 2) qualitative descriptive study; 3) mixed methods field test of a novel patient decision aid (DA). Systematic review findings. Of 3162 citations, four trials evaluated interventions to improve communication between health professionals and patients/families. One intervention met eight of nine criteria for SDM but did not evaluate its effect on the benefit to communication. Qualitative study findings. Six family members and nine health professionals identified two options (life support or comfort care) and values associated with these options. Values included maintaining quality of life, surviving critical illness, minimizing pain and suffering, not being attached to machines, giving the family enough time to adapt emotionally to the patient’s health situation, and the judicious use of healthcare resources. Families were unlikely to become engaged without healthcare professionals making the decision explicit and minimizing other barriers across the decision-making process. Field test findings. Family members and health professionals for eight patients indicated that the DA was feasible to use, acceptable to users, had the potential to do what was intended, and did not seem to present adverse consequences to users. An enhanced delivery strategy is needed for future evaluation of its effect on facilitating patient/family involvement in decisions. Conclusions. Limited involvement of families in the process of decision-making about life support in the ICU reinforced the need for effective interventions to facilitate SDM. These studies validated the operationalization of the IPDAS criteria, as part of a systematic process for developing and field testing DAs. However, IPDAS criteria stop short of elements necessary to consider when implementing the DA in the processes of care.

Purpose. To systematically develop and field test an intervention to engage families and healthcare teams in the decision-making process about life support for critically ill patients in the Intensive Care Unit (ICU). Setting. Adult medical-surgical ICU at a Canadian academic teaching hospital. Methods. The International Patient Decision Aid Standards (IPDAS) criteria and the Interprofessional Shared Decision Making (SDM) model guided the study of families facing decisions about life support for their relative in ICU that involved:1) systematic review; 2) qualitative descriptive study; 3) mixed methods field test of a novel patient decision aid (DA). Systematic review findings. Of 3162 citations, four trials evaluated interventions to improve communication between health professionals and patients/families. One intervention met eight of nine criteria for SDM but did not evaluate its effect on the benefit to communication. Qualitative study findings. Six family members and nine health professionals identified two options (life support or comfort care) and values associated with these options. Values included maintaining quality of life, surviving critical illness, minimizing pain and suffering, not being attached to machines, giving the family enough time to adapt emotionally to the patient’s health situation, and the judicious use of healthcare resources. Families were unlikely to become engaged without healthcare professionals making the decision explicit and minimizing other barriers across the decision-making process. Field test findings. Family members and health professionals for eight patients indicated that the DA was feasible to use, acceptable to users, had the potential to do what was intended, and did not seem to present adverse consequences to users. An enhanced delivery strategy is needed for future evaluation of its effect on facilitating patient/family involvement in decisions. Conclusions. Limited involvement of families in the process of decision-making about life support in the ICU reinforced the need for effective interventions to facilitate SDM. These studies validated the operationalization of the IPDAS criteria, as part of a systematic process for developing and field testing DAs. However, IPDAS criteria stop short of elements necessary to consider when implementing the DA in the processes of care.

Patient-centred care has become an important model for health-care delivery, especially in cancer care. The implementation of this model includes patient-centred communication between the clinician and his or her patient. However, most research on patient-centred communication focuses on the clinicians’ initiative: what clinicians should do and what information they should seek to elicit from patients. It is equally important to recognize what each individual patient can contribute about his or her unique perspective on the disease, its treatment, and the effects on what is important to this patient. This thesis reports the development of a system for analyzing over 1500 utterances made by patients in eight video-recorded oncology consultations at the British Columbia Cancer Agency, Vancouver Island Centre. The analysis distinguishes between biomedical information that the patient can provide and patient-centred information, which contributes the individual patient’s unique perspective on any aspect of his or her illness or treatment. The resulting analysis system includes detailed operational definitions with examples, a decision tree, and .eaf files in ELAN software for viewing and for recording decisions. Two psychometric tests demonstrated that the system is replicable: high inter-analyst reliability (90% agreement between independent analysts) on a random sample of the data set and cross-validation to the remainder of the data set. A supplemental idiographic analysis of each consultation illustrates the important role that patient-centred information played in these consultations. This system could be an important tool for teaching clinicians to recognize the individual information that patients can provide and its relevance to their care. / Graduate / 0992 / 0451 / 0350 / shealing@uvic.ca