Family/friend caregivers of persons with dementia often do not feel prepared for end-of-life, which contributes to high rates of complicated grief, depression and anxiety in bereavement. This mixed methods study used an exploratory sequential design to explore the core concepts and indicators of preparedness, develop and evaluate a multidimensional questionnaire aimed at measuring caregiver preparedness for end-of-life for persons with dementia. In Phase 1, a qualitative study with an interpretive descriptive design was used to explore the core concepts and indicators of preparedness with 16 bereaved family caregivers recruited from six long-term care homes located in Ontario, Canada. In Phase 2, a quantitative, cross-sectional Delphi-survey was conducted with 5 caregivers and 12 diverse professional experts to select preparedness indicators/items and develop the Caring Ahead questionnaire. Lastly in Phase 3, the self-report, paper format questionnaire was evaluated for evidence of validity and reliability using a quantitative cross-sectional design. In this final phase, the questionnaire was completed through the postal mail by 134 caregivers from over 50 long-term care homes/residential care facilities, primarily in Ontario, Canada. Evidence for internal structure and concurrent validity was generated along with reliability coefficients suggesting internal consistency and stability in a test-retest. Findings from this study contributed to the conceptualization and operationalization of preparedness and produced the new, multidimensional questionnaire titled Caring Ahead: Preparing for End-of-Life with Dementia with preliminary evidence for validity and reliability. This questionnaire aims to fill an existing gap expressed by researchers who aim to design and evaluate interventions promoting preparedness through a palliative approach. In addition, policy-makers should benefit from introduction of the Caring Ahead questionnaire as an outcome measure to monitor and evaluate the effectiveness of policies surrounding a palliative approach. / Thesis / Candidate in Philosophy / Providing care to a family member or friend with dementia can be very challenging and different than caring for persons with other disorders. Healthcare providers should provide a palliative approach to care which focuses on quality-of-life and helping family caregivers prepare for end-of-life. However, many family caregivers do not feel prepared for death and this can lead to serious mental health problems in bereavement. This thesis explores what feeling prepared for death means and describes the development and testing of a questionnaire to assess how prepared family caregivers feel for the end-of-life of someone with dementia. Through interviews and surveys with caregivers and professional experts, we developed and tested the Caring Ahead: Preparing for End-of-Life with Dementia questionnaire. Use of the new Caring Ahead questionnaire aims to help us understand how prepared family caregivers are feeling for end-of-life and what supports are needed.

Introduction Role identity theory explains that people derive a sense of purpose and meaning from holding social roles, which, in turn, is linked with health and well-being. Paramedics have a respected role in society but high rates of mental illness. I used role identity theory to explore what might be contributing to poor mental health among paramedics. Objectives My objectives were to estimate the prevalence of Post-Traumatic Stress Disorder (PTSD), depression, and anxiety; assess for relationships with a measure of paramedic role identity; and finally, explore how role identity conflict could lead to distress. Methods I used a mixed methods approach situated in a single paramedic service in Ontario, Canada, distributing a cross-sectional survey during the fall 2019/winter 2020 Continuing Medical Education (CMEs) sessions while also interviewing a purposively selected sample of 21 paramedics. The survey contained a demographic questionnaire, a battery of self-report measures, and an existing paramedic role identity scale. Each interview was transcribed verbatim and analyzed thematically with role identity theory as a conceptual framework. Results In total, 589 paramedics completed the survey (97% of CME attendees), with 11% screening positive for PTSD, 15% for major depressive disorder, 15% for generalized anxiety disorder, and 25% for any of the three. Full-time employees, women, those with ‘low’ self-reported resilience, and current or former members of the peer support team were more likely to screen positive. The dimensions of paramedic role identity were not associated with an increased risk; however, I defined a framework through the interviews wherein chronic, identity-relevant disruptive events contribute to psychological distress and disability. Conclusions Our prevalence estimates were lower than have been previously reported but point to a mental health crisis within the profession. Role identity theory provided a useful framework through which to reconceptualize stressors. / Dissertation / Doctor of Philosophy (PhD) / Role identity theory explains having a sense of purpose and meaning people from social roles (such as a parent or volunteer) is good for health and well-being. Paramedics are an important part of Canada’s public safety infrastructure and generally hold a respected position in society, but there is growing recognition of a mental health crisis within the profession. I used role identity theory to explore why and how role identity theory could contribute to poor mental health among paramedics. By surveying and interviewing paramedics from a single paramedic service in Ontario, Canada, I discovered that 25% of active-duty paramedics met the criteria for either post-traumatic stress disorder, depression, or anxiety. The risk varied across demographic categories, including gender. During the interviews, I discovered that role identity conflict – a discrepancy between what the paramedic thinks their role should be and what is achievable – can lead to significant psychological distress.

Background: An increasing number of mixed methods studies have been conducted across health care professions in recent years. However, little is known about the methodological reporting quality among mixed methods studies involving chiropractic research. Objective: To examine the methodological quality of published chiropractic mixed methods studies, provide recommendations for improving future chiropractic mixed methods research, and apply these recommendations in two mixed methods health services evaluations of chiropractic integration and prescription opioid use for spinal pain. Methods: We conducted a meta-epidemiological review of the chiropractic mixed methods literature and examined reporting quality using the Good Reporting of A Mixed Methods Study guideline and risk of bias using the Mixed Methods Appraisal Tool. We used generalized estimating equations to explore factors associated with higher methodological quality. We applied our findings in two sequential explanatory mixed methods investigations of the association between chiropractic care and opioid prescribing for non-cancer spinal pain. Results: Among eligible mixed methods studies, we found that many were both poorly reported and at risk of bias. Publication in journals with an impact factor and/or more recent publication were significantly associated with higher methodological quality. In our sequential explanatory analyses, we found that receipt of chiropractic care was associated with decreases in initial opioid prescribing and long-term opioid use, and our qualitative results suggested these relationships were multi-factorial. Conclusion: We identified areas for improvement in the methodological reporting quality of chiropractic mixed methods research. Our mixed methods studies suggest that integration of chiropractic services into primary care centres may reduce the use of opioids for spinal pain. / Thesis / Doctor of Philosophy (PhD) / We reviewed the literature to assess the methodological reporting quality of mixed methods studies involving chiropractic research and found that most studies had important omissions. We applied these results to optimize methodologic reporting of two mixed methods studies on the association between chiropractic care and opioid prescribing. We found that patients with non-cancer spinal pain were less likely to receive an initial prescription for opioids if they accessed chiropractic care. Further, among chronic pain patients receiving opioids, we found that providing access to chiropractic care reduced their chances of continuing to receive opioids. The qualitative aspect of our studies provided important context to inform how patients and their primary care providers felt access to chiropractic care had reduced reliance on prescription opioids. These findings will increase awareness among researchers for opportunities to improve reporting quality of mixed methods research and highlight the potential role of chiropractic care in helping to address the opioid crisis.

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<p> This mixed methods study seeks to explain women's decision making regarding intimate partner violence disclosure in urban emergency departments. It contributed to an overall program of research led by Dr. H.L. MacMillan examining the effectiveness of screening in health care settings to reduce violence and improve the quality of women's lives.</p> <p> The study included a randomized, controlled trial with a quantitative sub-analysis and a grounded theory approach. The trial goal was to evaluate whether routine screening for IPV in health care settings, as compared to usual care, does more good than harm. The quantitative sub-analysis included 1,182 participants from three trial emergency departments. In the sample, 1.9% were exposed to intimate partner violence disclosed to the health care provider. Of those who disclosed, 62.9% were positive on both the screening tool and criterion standard. The grounded theory phase involved 19 participants and sought to examine the problems that trial participants associated with intimate partner violence disclosure and the processes they used to resolve them.</p> <p> "Being found out" was the basic social psychological problem that influenced women's decisions against disclosure. This led to a three-phase process where participants attempted to "minimize their risks." The basic social psychological process included: (a) deciding to seek health care, (b) evaluating trust in the clinician, and (c) establishing internal readiness for disclosure. Participants stated that the emergency department was not an ideal place to disclose violence due to overcrowding, chaos, long wait times, and a lack of privacy. Results indicated that abused women wanted clinicians to offer empathy and support, and to minimize the intrusion caused by assessment. Clinician education is required to improve communication, client engagement and comfort discussing intimate partner violence. Future research could explore the barriers and facilitators to care quality and patient satisfaction among abused women seeking emergency care.</p> / Thesis / Doctor of Philosophy (PhD)

This mixed methods study sought to refine the causal explanations for racial disparities in mental health care by exploring with youth of color (YOC, ages 12–21) how they became candidates for psychiatric care (“candidacy”). The thesis focused on developing and testing hypotheses about the Candidacy Model (CM) as a mediator of the relationships between mental health needs, racism, and health care utilization; examining those relationships when the candidate for care was represented by an agent; and characterizing how YOC and their agents experienced the assertion and adjudication stages of CM during a psychiatric emergency services visit. Despite a rich and growing literature on patient and environmental factors associated with lower access to psychiatric services, health services research in the United States has paid little attention to how YOC actualize their candidacy for mental health services. The CM suggests that vulnerable populations must negotiate with health care systems to have their needs considered medically treatable and to experience treatment in conditions that are congruent with their lifestyles. Theorizing that CM acts as a mediator between healthcare needs, racism, and treatment, this thesis explored how the specific stages of CM influenced mental health outcomes for YOC. The hypothesized relationships between candidacy, needs, racism, and utilization were tested using data from two national surveys, and in two different contexts: among young adults (ages 18-21) and among adolescents (ages 12–17) whose candidacy was co-constructed with their guardians. Through qualitative research (interviews and observation), over two years the research team explored with YOC and their guardians how current and prior candidacy experience influenced their use of psychiatric emergency services, an undesirable source of mental health care, and often the last resort for patients unable to access ongoing care. I found limited evidence that CM stages mediated the relationship between health care needs and treatment. Experiencing racism decreased the likelihood of being a successful candidate for care. Explorations with YOC and guardians found that people of color were marginalized when their assertions were ignored and when they were excluded from mental health care decision making. Repeat visits to the psychiatric emergency room reflected a negotiation strategy, in which the YOC and guardian triangulate and learn over time how to negotiate for a desired outcome. This thesis deepens knowledge of CM and of the role of negotiations in mental health care access for YOC, providing theoretical insights that will inform interventions to improve mental health equity. / 2025-08-23T00:00:00Z

Despite much attention given to effective teams in the workplace, school counseling teams have been neglected in the research. The primary purpose of this mixed methods study was to learn what characteristics secondary counselors perceive contribute to an effective school counseling team. The first research phase conducted six team interviews; themes emerging from the interviews yielded the development of the Effective School Counseling Team Questionnaire (ESCTQ). The following research questions were investigated: What factors do counselors perceive contribute to their team's effectiveness?, Are the scores on the Effective School Counseling Team Questionnaire related to team effectiveness as described by school counselors? Is there a relationship between team characteristics (amount of time together, individual counseling experience, gender, age) and team effectiveness? Is there a relationship between the perceptions of members of effective and ineffective teams? The literature on effective team factors was reviewed and analyzed in three categories: internal, interpersonal, and external. Qualitative results indicated that the majority of participants viewed internal traits as the number one factor contributing to their team's success. Most frequent were competencies, respect, sharing duties, caring for each other and serving students. The second area participants listed as most important was interpersonal factors, such as communication, interactions, and planning. Overall, communication was cited as the number one factor needed for an effective team. Conclusions drawn suggested that teams need altruistic, personal qualities to feel most effective. These were summarized by participants as a team member who is caring, giving, and putting the needs of students first. The second key area for school counseling teams was support from external sources, primarily school administration and central office. In phase two, the questionnaire was developed and used to confirm the interview findings. During the second phase, the ESCTQ was administered to 199 secondary school counselors, yielding an 82.4% (n = 164) return rate. The survey when analyzed by teams did not show major significant differences between the teams; it did, however, confirm the qualitative findings of the internal and personal characteristics counselors of effective school teams posses. The survey also allowed team members to rate their current team and their ideal team. The difference between the two ratings (ie. gap score) showed there was a significant mean difference (20.50) between the means of those who perceived their team as highly effective (26.55) and those who perceived their team as least effective (6.05). When looking at the questionnaire this could be interpreted to mean that the team members who felt most effective had the smallest gap score between their current team and their ideal team. When teams' gap scores were compared to their overall team rating "global" scores, as the global score increased for a team their gap score decreased. Meaning an effective team had fewer discrepancies (smaller gap) between their current and ideal team. Clearly, teams that perceive their team as "relatively effective" are rating the team closer to their ideal team than those that see their team as "relatively ineffective". In order to enhance performance of a counseling team, this study was important to assess school counseling team's effectiveness. Two research methods were used to analyze effective teams; this research provides valuable information relating to school counselors and effective teams. / Ph. D.

Despite much attention given to school counselors and their roles, minimal research has been conducted with regard to parental expectations of school counselors and no research exists in how expectancy theory relates to parental motivation. The primary purpose of this mixed methods study was to explore parental expectations of the secondary school counselor's roles and to gain an understanding of how expectancy theory influences parental motivation. The following questions were researched: What are the attitudes and general beliefs that parents have regarding expectations of school counselors? What do parents expect their children to gain from working with secondary school counselors? How do parents' prior interactions with school counselors impact their expectations? Is there a relationship between parental expectations and what advice/encouragement parents give their children when consulting school counselors? The first phase consisted of a qualitative exploration of the expectations of secondary school counselors based on focus group interviews with fifteen parents. Qualitative results revealed that parents expect secondary school counselors to know and guide their child. In addition, parents expect their children to gain information and knowledge from their school counselor. Finally, it was determined that there was a relationship between what parents expect and the encouragement and advice parents gave their children about working with school counselors. Themes that emerged from the focus groups were used in the development of the Parental Expectation School Counselor Questionnaire (PESCQ) and to confirm the focus group findings. The PESCQ was administered to 450 parents of high school students in grades 9-12 at two SW Virginia high schools. The survey did not detect significant findings between demographic variables but did confirm qualitative findings of parental expectations and child gains. Clearly, parents who had expectations expected their children to gain knowledge and information from their school counselors and those parents were motivated to encourage their children to work with their school counselor. This study contributed to research on expectancy theory and analysis revealed that parents are motivated to work with counselors because they have shared values of wanting what is best for the child. This positive outcome equals a students' success. This research also provided implications for parents, school counselors, counselor educators, administrators, and school boards. Parents need to get to know their child's school counselor and become informed about their roles and functions. School counselors need to do their best to get to know their students and evaluate how they can motivate their parents to be more involved. Parents and school counselors share values of wanting the student to be successful. Since parents see the school counselor as a key to success and parents want to meet their child's needs this creates a motivation in working with the school counselor. / Ph. D.

The purpose of this study was to explore the aspects of therapy as proposed by "common factors" literature (e.g., extratherapeutic change, hope and expectancy, therapy technique, and therapeutic relationship) by surveying the clients of a university based family therapy clinic. Data were used to provide information about what factors are therapeutically helpful according to the client's perspective. Surveys provided a quantitative and qualitative description of the client's therapeutic experience and were compared with those aspects of therapy found in the research. Quantitative results indicate that therapeutic relationship, client motivation, factors outside of therapy, and hope and expectancy accounted for around 49% of the variance of clients' perception of change and about 73% of the variance of clients' perceptions of therapy helpfulness. Findings further suggest that the clients' level of hopefulness and expectancy for positive change is the most significant predictor for both client change and therapy helpfulness. Qualitative results indicate that the therapeutic relationship is considered by clients to be the most helpful aspect of their therapeutic experience. / Master of Science