Thèse (M.A.)--Université Laval, 2002. / Bibliogr.: f. [141]-148. Publ. aussi en version électronique.

Background: Socio demographic and epidemiological change, together with the availability of medical technology, may prolong the process of dying. Antecedent control over end-of-life care (EoLC) may be sought by making an advance directive (AD). This option has been legalised in some countries including Israel, the setting of this study. In Israel, EoLC is set in the context of complex and interrelated religious and state regulations. Aim: To examine from a variety of perspectives, the experiences, beliefs and practices associated with the use of ADs in Israel, with a view to understand their role in the lives of patients with palliative care needs towards the EoL. Methods: The study was conducted in 2011, using mixed methods in two phases. The first phase involved qualitative methods to construct patient-centred case studies. Twenty seven participants (patients, relatives, physicians and a Rabbi) were interviewed. In phase 2, a survey examined health care providers’ (HCP) knowledge, attitudes and experiences regarding ADs. The final sample (n=72) of HCPs comprised: 57 nurses (79%), 8 physicians (11%), and 7 social workers (10%). Findings: This study promotes the understanding that ADs reflect a multitude of steps that are distinct but linked, as in a ‘relay’. The findings demonstrate complexity: patients’ ADs reflected their desire for autonomy but their decisions were often influenced by their relationships. In turn, relatives feared making mistakes in decision-making, while also feeling obligated to enact the patient’s wishes. Physicians reported finding it difficult to forgo active treatments and found communication with relatives about patients’ ADs challenging. The survey showed that while HCPs had typically positive attitudes towards, and some experience with ADs, they also perceived some barriers towards their use. Conclusion: ADs seem as an imperfect solution to the complexities surrounding EoLC planning, and additional solutions than those available today may be required.

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In 2004 unexplained pedagogical barriers were limiting Learning Object (LO) development. Few reference points existed preventing the formation of specific pedagogical questions as to the nature of these barriers - hence this PhD's rationale. This thesis 'uncovers' the most effective pedagogical and evaluation/assessment* approaches for LO design in Medical Education, and the underlying principles within these approaches - i.e. what is effective, and why. To determine why certain approaches are effective observation/interview/usability studies were performed using grounded theory to generate hypotheses (1A Participants n=57). To verify 1A findings, this process was replicated using different sites/samples in Phase 2(Eastern/Midlands, n=72). To determine what was most effective, systematic reviews using a purpose-built design were undertaken with additional questions on pedagogy and evaluation/assessment• components (1B Studies n=222). Approaches identified as 'effective' according to statistics, SCIE and my own rigor scoring systems were tested blind in two locations (Eastern/Midlands) with different samples under a null hypothesis (i.e. 'Each approach will score no differently to any other', Phase 2 participants n=72). This was further developed by replicating this process via mobile delivery. Section 1A generated over a hundred hypotheses. In Section 1B, two existing approaches scored consistently high. Phase 2 produced the same hypotheses/approaches when submitted to the blinded observation/interview/usability process thus tight theme linkage resulted in rigorous theory and empirical data. The two top-performing 1B approaches scored high resulting in the possible existence of generic principles. When replicating 1A, 1B and Phase 2 for mobile delivery, the existence of generic principles was verified and a possible model for practice formed. In summary, this thesis underlines the importance of learner input and how learners' perceptions form an essential part of the LO learning process. It discovers original generic principles for both desktop and mobile formats, highlights how branch and loop learning systems are necessary for learner customisation, and provides new knowledge verifying Wiley's molecular LO analogy. *In this thesis many types of evaluation approaches are tested. These are called 'evaluation approaches' by the authors that created them. However, in some disciplines the term 'evaluation' is viewed as being interchangeable with the term 'assessment'. For this reason explanatory footnotes will be given throughout where necessary.

Background: The Quality Outcomes Framework (QOF) was introduced in April 2004. Research to date has primarily looked at its effects on process and surrogate outcomes measured in primary care rather than evidence linked hospital admissions. None has used individual linked data. This study utilises data linkages between the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES) datasets to determine the impact of QOF targets on hospital admissions at the individual patient level. Methods: CHD QOF targets and linked hospital admissions were selected according to the strength of their evidence base and ease of extraction. Outcomes were ICD10 codes for Ischaemic Heart Disease (IHD). These formed the primary diagnosis over a hospitalisation and depending on the severity of the code, were additionally an emergency admission. Econometric analysis was then undertaken with IHD admissions as the dependent variable and evidence based CHD QOF targets as explanatory variables. Results: Evidence based CHD QOF targets were found to significantly reduce outcomes after a one year lag. Of the co-morbidities included, only Heart Failure was consistently found to significantly increase outcomes in all analyses. Higher deprivation, and having a study outcome prior to CHD diagnosis, significantly increased outcomes. Being treated in a higher performing practice on the selected targets, in itself, significantly reduced outcomes. Conclusion: This study has demonstrated at the individual level that evidence linked targets in the QOF are effective in reducing linked hospital admissions with a lag. It is the first study to take advantage of CPRD and HES linkages to do so. This has been demonstrated in a ‘real’ world setting, outside of controlled clinical settings, and in so doing addressed deficiencies identified in the existing research. This research has shown that large administrative datasets can support such research and opened up a number of possibilities for future research.

Thesis (Ph.D.)--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. / Neotropical montane forests of the Ecuadorian Andes harbor a disproportionate amount of global biodiversity, yet the ecological and evolutionary processes that generate and sustain this diversity are poorly known. Determining the relative roles of historical vicariance, natural selection and genetic drift in generating diversity are active areas of investigation, but no clear pattern has emerged. My research focuses on a direct developing cloud forest frog ( Pristimantis w-nigrum ) found along the Eastern and Western versants of the Ecuadorian Andes. By integrating morphological data, multi-locus sequence data and geographic and environmental data, I demonstrate that: (1) Pristimantis w-nigrum harbors substantial genetic diversity, despite morphological stasis, and may comprise a species complex; (2) Genetic differentiation of mitochondrial DNA identifies eight divergent lineages and highly structured populations along both eastern and western slopes of the Ecuadorian Andes; (3) Multiple nuclear markers show lesser but still substantial population structure; (4) Isolation by distance best explains the pattern of genetic variation, but temperature and precipitation also contribute to genetic and morphological variation; (5) The timing of genetic divergence among mtDNA lineages coincides with sequential paleogeological bouts of Andean orogenesis during the late Miocene and early Pliocene, with terminal lineages diverging during the Pleistocene; (6) Populations have experienced little or no gene flow. (7) Those on the Western slope have maintained large effective population sizes, while populations on the Eastern slope appear to have suffered severe bottlenecks. Taken together, these results suggest a long sequential history of vicariance following the orogeny of the Northern Andes and that allopatric speciation may be a common mode of divergence in montane ectothermic vertebrates with low vagility. In addition, estimation of the species phylogeny and historical and contemporary demographic parameters using multiple loci highlight the utility of a multi-locus approach, particularly in cases where diversification may have occurred relatively recently. The identification of cryptic diversity in the P. w-nigrum suggests that evolutionary processes of isolation and divergence are occurring in the Andes and that the Andes may be an important generator of new species as well as a repository of high biodiversity. / 2031-01-01

Background Effective disease diagnosis and treatment relies on a conceptual knowledge base that is both expansive and well-networked. The problem-based learning (PBL) curriculum is considered as being well-suited to creating this kind of knowledge. The facilitator plays a crucial role in establishing and maintaining the knowledge construction discourse as students interact to resolve case problems. An exploration of tutorial talk could provide opportunities to understand and improve verbal interactions of this nature. Many of the previous studies have only analysed a small amount of tutorial talks owing to methodological constraints, and the existing literature on the subject matter only scarcely touches upon the utility of lexicogrammatical methods for the development of an understanding of knowledge construction in medical PBL tutorials. In this research, a blend of corpus linguistics methodology and a lexicogrammatical approach was employed for the analysis of talk in 8 PBL tutorial groups in order to deepen our understanding of how students jointly construct knowledge and how the facilitator guides the process. Aims In this study, a corpus of 2,37,820 comprising eight PBL students’ and facilitators’ tutorial talk was created to achieve the following aims: I. To use the students’ subcorpus to answer the research question (1) by measuring the frequencies and describing the functions of the frequently occurring (1) referring expression indicators; (2) shared knowledge indicators; (3) knowledge extension indicators; and (4) knowledge enhancement indicators. II. To use the facilitators’ subcorpus to answer the research question (2) by measuring the frequencies and describing the functions of the commonly occurring (1) facilitators’ questions; (2) facilitators’ directive expression indicators; and (3) facilitators’ probability indicators. III: To make recommendations based on the results of the study. Methodology Wmatrix 3 was used to retrieve defined linguistic indicators relating to the research questions. A quantitative analysis of the indicators was performed through word frequency computation and a keyword-in-context analysis. Descriptive statistics with SPSS version 22 was used to computer frequency profile of the indicator functions, and the Log likelihood calculator was used to determine the variation of the functions across the eight PBL groups. Extracts from the dataset were provided to illustrate the indicators’ functions. I. Results of Students’ talk analysis The subcorpus contained 2,10,077 words. The most frequent contents of the students’ talk comprised biomedical science and cause-effect vocabularies. 1. Analysis of referring indicators There were 2,325 referring expression indicators. They were used to mark verbal expressions, amounting to 44.04%; mental expressions, amounting to 42.24%; and learning situation and materials, amounting to 13.72%. The referring expressions were used for providing peer commendation, sharing knowledge, fostering social and cognitive regulation, and for constructing knowledge; the mental referring expressions were used to generate hypotheses, achieve mutual understanding, and define group tasks; and learning referring expressions were used to share learning resources, explain concepts, as well as guide discussions and resolve conflicts. 2. Analysis of shared knowledge indicators There were 3,437 shared knowledge expression indicators, which are the following: affirmation (73%), negation (17%), and non-lexical content (10%). Affirmative indicators were mostly used for integration-oriented knowledge sharing (42.31%); negation affirmation expressions were mostly used for conflict-oriented knowledge sharing (70%); and non-content indicators were mainly used for idea and information orientation. Shared knowledge was commonly achieved among group members through information addition, repetition and rephrasing, paraphrasing, causal and noncausal elaboration, correction of ideas and information recollection, and by establishing orientation to ideas and information from the group members. 3. Analysis of knowledge extension indicators There were 6,520 retrieved knowledge extension indicators, which comprised the following: additive 4,227 (63.54%), alternative 1,001 (15.05%), and adversative 1,424 (21.41%). Adversative indicators were more frequently used for knowledge construction compared to additive (33% versus 16%; LL 32.58, p < 0.01) and alternative indicators (33% versus 13%; LL 95.74, p < 0.01). The students commonly used additive indicators for simple, temporal, causal-conditional, elaborate, contrastive, and indefinite additions. Alternative indicators were commonly used for offering alternative questions and ideas while adversative indicators were frequently used to link elaborative, contrastive, concessional, and causal-conditional clauses. 4. Analysis of knowledge enhancement indicators A total of 6,402 indicators were retrieved. The most frequent among the retrieved 6,402 indicators were because, so, as, when, and that. Between 16.94% and 29.24% of the indicators were used for knowledge co-construction. The most frequent indicators’ functions were conditional, extension, report, consequence, inference, and feature specification. The reporting functions regularly concerned biomedical theory, previous peer knowledge, research evidence, professional opinion, as well as cognitive tools and criticism; extension function related to biomedical knowledge; and feature specification functions involved biomedical attributes and explanation; the conditional functions were frequently used to state logical conditions for disease presence, manifestation, and treatments; the inferential functions were more consistently used to link biomedical deductions to their premise; and the consequential functions commonly related to the linking of physiological mechanism and organ function to their respective consequences. II: Results of facilitators’ talk analysis The subcorpus contained 27,743 words. The most frequent content comprised biomedical science and cause-effect vocabularies. 1. Facilitators’ questions There were 35 types of question indicators. The facilitators asked 0.78 lower-order questions per 100 tokens, and 0.25 higher-order questions problem-based per 100 tokens. The questions functioned to stimulate elaboration, elicit information, prompt students, and the offering of suggestions. 2. Analysis of directive expressions ‘Should’, ‘have to’, ‘need’, ‘supposed’, ‘would’, and ‘can’ directive expression indicators were found to be most frequent. They were used to mark expectation, indirect question, and they were commonly used to preface requirement, exhortation, and intention. The indicators functioned frequently to facilitate group process (53.45%) and direct learning (42.00%). 3. Analysis of probability expression indicators There were of 27 types, out of which 9 were frequently occurring. The probability expression indicators were frequently used to mark possibility, prediction, hedging, and logical deductions. The indicators functioned to preface content information given to the students, to mark process facilitation remarks, and to mark facilitators’ questions. Discussion and conclusion The study demonstrated the feasibility of using corpus linguistics to study medical students’ knowledge construction talk; provided evidence of knowledge construction through prior knowledge mobilisation, knowledge extension, and enhancement; and signified the attainment of shared knowledge. The facilitators frequently asked lower-order questions; the directive expressions indicators were used to mark content-related and learning behaviour expectations and requirements; and the probability expression indicators were frequently used to mark content information given to the students. This study shows that students construct knowledge in their PBL tutorials. The pedagogic issues that emerged from the study relates to subversion of the PBL facilitation principles. A wholistic understanding of the factors that affect the behaviours of the facilitators in the classroom is important to resolve this problem. This may involve tutor pedagogic education and recalibration of administrative policies and institutional culture to provide an enabling environment for PBL instructional approach.

This thesis explores and tests an integrated, social cognitive approach to understanding leadership and developing leaders within healthcare organisations in the United Kingdom. Two studies were implemented; the first involved an assessment of the personal and environmental components of leaders and their followers, as well as the self-reported and follower-rated behaviour of leaders in eight National Health Service (NHS) organisations. The second study involved working with 15 organisations across the NHS to implement and evaluate a scenario-based training intervention which promotes a social cognitive perspective of leadership and draws on the principles of adult learning. The impact of this intervention was examined using a longitudinal design and factors influencing the transfer of leader self-efficacy were explored. For both studies, the suitability of measures was assessed and validated using confirmatory factor analysis. Specific analytic techniques were used within each study based on the study objectives. In study I, mediation analyses were conducted using Structural Equation Modelling (SEM) to explore the interaction between personal, environmental and behavioural components within leaders, as well as exploring how these components interact in the relationship between the leader and their followers. The results revealed a significant mediational role of two key aspects of the perceived environment (control and social resources) in the relationship between leaders’ behaviour and followers’ personal components and attitudes towards work. The mediational role of leader behaviour in the relationship between leaders’ personal components and their perceived environment was not supported. Study II used a Multivariate Analysis of Variance (MANOVA) with a repeated measures design to explore the impact of training over time on leaders’ awareness of what constitutes ‘supportive’ leadership behaviour and their self-efficacy judgements. Data was collected immediately prior to attendance at the training intervention, immediately after training and 6 months post-training. The results revealed a significant increase in leaders’ self-efficacy post-training in relation to four common situations that leaders within healthcare settings face. The longitudinal analysis also showed that leaders’ self-efficacy beliefs were maintained 6 months post-training. In addition, an assessment of leaders’ behavioural awareness indicated that democratic leadership behaviours and behaviours relating to greater self/other awareness were seen to be significantly more supportive immediately after training compared to pre-training (baseline) levels. There were no significant differences in leaders’ awareness of the supportiveness of performance and target-driven behaviours immediately after the training. However, the longitudinal analysis revealed that leaders’ increased awareness of the supportiveness of these behaviours was not sustained over time. Instead, these behaviours were seen to be significantly less supportive 6 months after training compared to both the immediate post-training and pre-training levels of awareness. Finally, a Hierarchical Multiple Linear Regression (HMLR) analysis revealed that the transfer of leaders’ self-efficacy beliefs (as assessed 6 months post-training) was significantly predicted by leaders’ pre-training (baseline) and post-training self-efficacy levels, as well as leaders’ age. Contrary to what was expected, application of their learning, post-training support from colleagues and supervisors and the interaction between support and the application of learning did not predict leaders’ self-efficacy 6 months after training. This thesis concludes by discussing the implications for leadership research and leadership training within healthcare organisations.