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Impaired wound healing in SCI patients contributes to the progression in severity of PIs. Best practice guidelines suggest that surgical flap reconstruction is an option for chronic stage 4 PIs that have failed to heal with more conservative measures, but little is known about the epidemiology of surgically reconstructed PIs in SCI patients. Rates of surgical wound complications are high, and cost of management is extensive. Accordingly, this study aims to establish a systematic approach for identifying SCI patients with surgically reconstructed PIs, to facilitate study of predictors of sustained wound closure, quantify costs of surgical reconstruction, and evaluate efficiency of treatment and recovery options. To address gaps in the literature, this study’s objectives were: (1) estimate surgical reconstruction hospital costs for stage 4 PIs in SCI patients and characterize the relationship of demographic, socioeconomic and lifestyle factors to cost at discharge, (2) explore a standardized method of identifying these cases in large databases, (3) identify and validate risk factors for complications at discharge from wound care follow-up, and (4) identify long-term cost and health care utilization of persons with SCI who have undergone surgical flap closure. It proved difficult to identify our own cohort of patients using administrative codes applied, making population-based study using administrative data less than ideal. Factors associated with open incision at three-to-six weeks post-index surgery included number of nursing visits in the previous year, and revision surgery within the six-week follow-up period. The cost of persons with SCI and PI was high one year prior to surgery (look-back) and almost double in the first year look-back. However, significant cost and health care utilization was demonstrated in Year 2 and 3 post-index surgery. Further prospective studies exploring models of health care delivery and addressing some of modifiable risk factors may improve cost-effectiveness and outcomes. / Thesis / Doctor of Philosophy (PhD) / Pressure ulcers, also known as pressure injuries (PI) or bedsores, are a common secondary complication in persons with spinal cord injury (SCI). While surgical closure is an option offered to patients, little is known about the long-term outcomes, including cost and use of health care services following the surgery. Risk factors for complications following surgery are known from a physical/co-morbidity/technique perspective, but environmental and behavioural factors have not been included these studies, and the use of health care administrative databases to accurately identify these patients for research has not been studied. A historical cohort study was conducted at one tertiary care centre in Toronto, Canada to identify known cases of SCI and PI reconstruction. Hospital codes were recorded in an algorithm used to evaluate the accuracy in identifying the known cases in the database. Health care usage and costs were also recorded, and risk factors for complications were also evaluated.

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Within the growing literature on team leadership, there is a lack of understanding which leadership process may be most reflective of intratsk leadership. In study 1, I explored leadership behaviors throughout the operating team's OR tasks and if a shared leadership approach is related to psycho-social attitudes and performance of the team. I also investigate surgical teams' engagement in safety related behaviors and if these are related to the team's workflow disruptions. As an exemplar environment, I chose to observe these dynamics in the operating theater, which is a high-stakes environment that necessitates the team to use both technical and non-technical skills. In study 2, I investigate whether a brief targeted leadership coaching sessions with residents in a simulated environment results in different (increase or decrease) leadership behaviors at an interval of 6 months. Multiple hypothesized models were tested in Study 1. The results of model 1 show that psychological safety and team trust are significantly correlated to each other (r=.704, p= <.001). The results show that psychological safety (β= -.505 p=.049) is related to performance (time of patient on bypass), while team trust (β= .177 p=.303) does not predict performance. The results of model 2 show that more extensive shared leadership behaviors are not significantly correlated with psychological safety (r=.087 p=.250) and performance (r=-.085, p =.295); however, the results show that there is a significant correlation with shared leadership and team trust (r=.260 p =.023), indicating that a more extensive shared leadership approach is related to higher team trust in a surgical team. The results of model 3 show that the length of the time-out (a safety critical behavior) does not mediate the relationship between perceptions of the usefulness of the time-out and frequency with which the circulating nurse leaves the operating room (OR). However, there is a strong relationship between the perceptions of the time-out and the number of times the circulating nurse leaves the OR (β = -.425, p<.001), indicating that for every unit increase in the perceptions of the usefulness of the time-out, the nurse leaves the OR .45 fewer times. In study 2, a paired sample t-test was conducted to understand if leadership behaviors post-coaching session are more frequent than pre-coaching session. The results show that there is no significant difference in the frequency of leadership behaviors at time 1 (M =.113, SD=.040) and the leadership behaviors at time 2 (M= .127, SD= .041); t (6)= -1.216, p = .270. / Doctor of Philosophy / Within the growing literature on team leadership, there is a lack of understanding which leadership process may be most reflective of intratsk leadership. In study 1, I explored leadership behaviors throughout the operating team's OR tasks and if a shared leadership approach is related to psycho-social attitudes and performance of the team. I also investigate surgical teams' engagement in safety related behaviors and if these are related to the team's workflow disruptions. As an exemplar environment, I chose to observe these dynamics in the operating theater, which is a high-stakes environment that necessitates the team to use both technical and non-technical skills. In study 2, I investigate whether a brief targeted leadership coaching sessions with residents in a simulated environment results in different (increase or decrease) leadership behaviors at an interval of 6 months. Multiple hypothesized models were tested in Study 1. The results of model 1 show that psychological safety and team trust are significantly correlated to each other. The results show that psychological safety is related to performance (time of patient on bypass), while team trust does not predict performance. The results of model 2 show that more extensive shared leadership behaviors are not significantly correlated with psychological safety and performance; however, the results show that there is a significant correlation with shared leadership and team trust, indicating that a more extensive shared leadership approach is related to higher team trust in a surgical team. The results of model 3 show that the length of the time-out (a safety critical behavior) does not mediate the relationship between perceptions of the usefulness of the time-out and frequency with which the circulating nurse leaves the operating room (OR). However, there is a strong relationship between the perceptions of the usefulness of the time-out and the number of times the circulating nurse leaves the OR, indicating that for every unit increase in the perceptions of the usefulness of the time-out, the nurse leaves the OR .45 fewer times. In study 2, a paired sample t-test was conducted to understand if leadership behaviors post-coaching session are more frequent than pre-coaching session. The results show that there is no significant difference in the frequency of leadership behaviors at time 1 and the leadership behaviors at time 2.

Surgical castration of young male piglets is an extremely common husbandry procedure in the United States swine industry, with nearly 100% of males castrated. The procedure is performed primarily to prevent the occurrence of boar taint in the meat and to reduce aggression as the animals age. No research has investigated the impact of surgical castration on the long-term mood states – also known as the affective state – of piglets, but it has been proven to cause both acute and chronic pain that can last up to 4 days, modify piglet behavior, and reduce weight gain. Because of this, feasible approaches for pain alleviation are needed. A hinderance to this is that currently no analgesics are approved for piglets. In addition, we need validated, practical methods to recognize pain in piglets in order to help researchers, veterinarians, and caretakers to identify the need for analgesics. One useful tool for this could be the Piglet Grimace Scale, which has previously been validated in this context, but is not widely applied. The current lack of analgesic use during castration may be cause for concern for consumers, however little is known about the public's knowledge on the industry's practices. Therefore, the thesis' objectives are to (1) assess the impact of surgical castration on pain and affective states, (2) determine people's ability to recognize pain expression after surgical castration, and (3) get insights into public perception of swine industry practices. In Chapter 3, we assessed the impact of surgical castration and practical pain alleviation methods during and after castration on piglets' short and long-term affective states and activity levels. Piglets were surgically castrated, castrated with analgesics, or sham-handled at 3 days of age. Data on piglets' activity (using accelerometers), tails (affective states), and grimaces (pain expression) were collected for 1, 6, and 24 hours after castration treatments while piglets were in their home pens. An attention bias test was then performed in week 1 and 12 to assess anxiety (an affective state). Home pen activity after castration treatments suggested that there was a positive impact of using analgesics. The piglets' behavior (eating) and activity during the attention bias test at week 1 suggest a negative impact of castration on affective states. The differences observed in week 1 were no longer found in week 12, suggesting that any impact of surgical castration at 3 days of age on affective states are no longer detectable at 12 weeks of age. In Chapter 4, through an online survey we investigated the validity and reliability of Piglet Grimace Scale ratings applied by swine industry professionals and the general public, to assess its potential utility in non-research settings. The survey contained a training, followed by 9 piglet images showing facial expressions immediately after castration or sham-handling. Both response groups were able to recognize pain in castrated piglets. However, both response groups overestimated pain experience compared to trained experts, suggesting more training may be necessary. Nevertheless, overall, the scale can be widely applied by veterinarians, industry professionals and even members of the public. In Chapter 5, a survey provided initial insights into public knowledge and perceptions on castration and analgesia use and compared this to industry stakeholders. The results show that knowledge on industry practices was especially lacking for public respondents, but also for a minority of industry respondents, indicating opportunities for education and further research on the topic. / Master of Science / Surgical castration is performed on nearly every male piglet in the United States swine industry. Males are castrated to prevent the occurrence of boar taint and to reduce aggression. Boar taint is the unpleasant odor produced by the skatole and androsterone in the fat when the meat is prepared. It is unclear how this practice impacts piglet's long-term mood states (affective states), but we do know it causes pain, changes in behavior, and reduced productivity. Thus, we need feasible approaches for pain relief. However, there are currently no pain relievers approved for piglets. In addition, we need validated, practical methods to quantify pain in piglets in order to identify the need for pain relief. One useful tool is the Piglet Grimace Scale, which is validated but is not widely applied. The current lack of pain relief use during castration may concern consumers, yet no data is collected on this. Therefore, the thesis' objectives are to (1) assess the impact of surgical castration on pain and affective states, (2) determine people's ability to recognize pain expression after surgical castration, and (3) get insights into public perception of swine industry practices. In Chapter 3, we assessed the impact of surgical castration and practical pain alleviation methods during and after castration on piglets' short and long-term affective states and activity levels. Piglets were surgically castrated, castrated with analgesics, or sham-handled at 3 days of age. Home pen activity after castration treatments showed a positive impact of using analgesics. The piglets' behavior and activity during an attention bias test at week 1 suggest that piglets were experiencing a negative emotional state after castration. The differences seen in week 1 were no longer found in week 12. This suggests that any potential impact of surgical castration on affective states are no longer detectable at 12 weeks of age. In Chapter 4, an online survey was used to investigate the Piglet Grimace Scale ratings applied by swine industry professionals and the general public. After training, respondents scored 9 images showing facial expressions of piglets after castration or sham-handling. Both public and industry people were able to recognize pain in castrated piglets. However, both response groups overestimated the pain experience compared to trained experts, suggesting more training may be necessary. Nevertheless, overall findings suggest that the scale can be widely applied. In Chapter 5, a survey provided insights into public knowledge and perceptions on castration and pain relief use in the industry, and compared this to industry stakeholders. The results showed that knowledge on industry practices was especially lacking for public respondents, but also for a minority of industry respondents, indicating opportunities for education and further research on the topic.

The integration of artificial intelligence (AI) and machine learning in the medical field has led to significant advancements in surgical robotics, particularly in enhancing the precision and efficiency of surgical procedures. This thesis investigates the application of a single-layer bidirectional Long Short-Term Memory (BiLSTM) model to the JHU-ISI Gesture and Skill Assessment Working Set (JIGSAWS) dataset, aiming to improve the recognition and classification of surgical gestures. The BiLSTM model, with its capability to process data in both forward and backward directions, offers a comprehensive analysis of temporal sequences, capturing intricate patterns within surgical motion data. This research explores the potential of BiLSTM models to outperform traditional unidirectional models in the context of robotic surgery. In addition to the core model development, this study employs evolutionary computation techniques for hyperparameter tuning, systematically searching for optimal configurations to enhance model performance. The evaluation metrics include training and validation loss, accuracy, confusion matrices, prediction time, and model size. The results demonstrate that the BiLSTM model with evolutionary hyperparameter tuning achieves superior performance in recognizing surgical gestures compared to standard LSTM models. The findings of this thesis contribute to the broader field of surgical robotics and human-AI partnership by providing a robust method for accurate gesture recognition, which is crucial for assessing and training surgeons and advancing automated and assistive technologies in surgical procedures. The improved model performance underscores the importance of sophisticated hyperparameter optimization in developing high-performing deep learning models for complex sequential data analysis. / Thesis / Master of Applied Science (MASc) / Advancements in artificial intelligence (AI) are transforming medicine, particularly in robotic surgery. This thesis focuses on improving how robots recognize and classify surgeons' movements during operations. Using a special AI model called a bidirectional Long Short-Term Memory (BiLSTM) network, which looks at data both forwards and backwards, the study aims to better understand and predict surgical gestures. By applying this model to a dataset of surgical tasks, specifically suturing, and optimizing its settings with advanced techniques, the research shows significant improvements in accuracy and efficiency over traditional methods. The enhanced model is not only more accurate but also smaller and faster. These improvements can help train surgeons more effectively and advance robotic assistance in surgeries, leading to safer and more precise operations, ultimately benefiting both surgeons and patients.

No / Little is known about the career decisions qualified nurses make, although it is clear that some areas of practice are more popular than others. This qualitative descriptive study considers one common area, surgery, and explores the motivation for decisions made by Registered Nurses (RNs) to work in this area. A sample of 16 RNs working within surgical areas participated in semi-structured interviews, using a thematic interview schedule. Findings were analysed using the framework suggested by Morse and Field. Analysis of findings indicates that all participants actively chose to work within surgery and that this was because of the pace and turnover of surgical work, personal satisfaction at the recovery of patients; the close links between this type of work; and participants' original aims when first entering nursing and participants' preference of surgery to other areas of nursing work. Participants actively rejected working in areas where patients were likely to suffer from chronic long-term conditions where recovery was unlikely and felt that these areas were likely to be depressing and unrewarding. These findings suggest that participants actively chose to work with 'healthy' patients in preference to those who may be considered 'ill', and this is closely linked to the identified need of participants to be able to 'make patients better'. Participants were reluctant to work in areas where they would be unlikely to achieve this aim.

Thesis (M.S.)--Boston University / PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you. / Nurses are subjected to occupational stress factors that can result in the syndrome of burnout. This study compared levels of burnout in nurses in a medical-surgical ICU setting to those in non-ICU medical-surgical settings. A randomized sample of 40 nurses of an urban hospital in Taiwan, twenty nurses in an ICU and 20 in five non-ICU settings (general medical-surgical wards), who returned the questionnaire used to measure burnout, were included in the study. The instrument utilized was the Staff Burnout Scale for Health Professionals. The study found no significant difference in levels of burnout in the two groups. Both groups in this study experienced a higher level of burnout than was reported in other studies in United States literature. In particular, two general medical-surgical wards which had high patient/nurse ratios, had very high levels of burnout. The study also found that all nurses with lower educational levels and ICU nurses with more years of work experience had more burnout. / 2999-01-01