Communication concerning the care one wishes to receive at the end of life (EOL) is central to ensuring that wishes are honored. Many studies have examined doctor-patient or doctor-family EOL communication. However, relatively few studies have focused on the occurrence of EOL care discussions among family members. This is an important topic, as research suggests that advance directives (ADs) are ineffective if patients have not involved surrogate decision-makers, most of whom are family members. This study examined EOL care discussions among family members. It used quantitative and qualitative data from a diverse sample of older adults from West Central Florida collected for the purpose of this examination. The quantitative and qualitative data were analyzed separately and together. This study employed the Transtheoretical Model, which proposes that individuals are in varying behavioral “stages of change” and that bringing about a behavioral change requires understanding their particular stage and adapting interventions appropriately. Statistical analysis of the quantitative data (N=364) using multinomial logistic regression showed that participants were in distinct stages that were associated with several factors, including family involvement with health care decision-making and communications with doctors. Racial and ethnic differences were not found in controlled analysis, though Hispanics were less likely to be in more advanced EOL care discussion stages in unadjusted analyses. Several themes were found in qualitative analysis of focus groups (n=36) drawn from the larger sample. Findings suggested that those who engaged in family EOL care discussions were more careful planners overall, more accepting of death, and able to manage complex family dynamics. They also had greater knowledge of EOL matters, largely related to knowledge of loved ones EOL wishes. The quantitative-qualitative (mixed-methods) study reinforced the role of family relationships in general in whether EOL care discussions occurred. It also highlighted the role of being proactive and having EOL care knowledge. All three studies – the quantitative, qualitative, and mixed methods showed the potential for doctors and other health professionals to help families with EOL care discussions and ACP overall.

Beginning in earnest in the 1990s, research and political communities have taken a strong interest in citizenship education both in Canada and worldwide, but in the context of secondary schools this has resulted in primarily theoretical papers rather than empirical analyses of student experiences. The student voice is particularly important to the study of citizenship education given the complexity of constructed civic subjectivities and the rapidly changing definitions of community, including the relationships between local, national and global. Canada has been characterized as post-national or even without identity, and its young people are caught up in the persisting narrative of young apathy when it comes to politics and civic duty. Drawing on theories of national and global citizenship, this exploratory mixed methods study of 104 British Columbian secondary students investigates student vocabularies of citizenship in order to map current youth understandings of citizenship and experiences in their secondary education. In discussing the results, I challenge the narratives of Canada as a meaningless signifier and youth as apathetic, and investigate scholarly concerns regarding the depoliticization of citizenship, and the potential conflict inherent to the globalization of youth identities. Finally, I discuss best practices in citizenship education with reference to established scholarly research and the student-based findings of the present study. / Graduate

Morale is a commonly used term both in business and society but the concept of morale is relatively poorly defined and understood. In a recent paper Liefooghe et al. (2004) expressed surprise that "when reviewing the literature, no strong theory to explain morale as such is in evidence, nor are there many empirical studies that offer solid ground to advise organisations"(p 1). This thesis aims to provide these theories and this empirical evidence in order to produce a better understanding of morale. This research identifies a number of deficiencies in the current understanding of morale. These range from elision with other concepts to disagreement about whether it is an individual or group phenomenon. In this study, four principal domains are examined: (i) what morale is; (ii) how it differs from other concepts; (iii) the antecedents of morale and (iv) its consequences. A mixed methods approach was adopted combining idiographic and nomothetic research. The idiographic phase of the research adopted a Straussian (1998) grounded theory approach, involving data collection from seven different organisations. The data was accrued from a combination of site visits, informal contacts, external research, and 203 semi-structured interviews which were supplemented with psychometric instruments. The data were then coded and analysed. Morale could be readily differentiated from other concepts and emerged as a phenomenon with three dimensions: affective, future/goal and interpersonal. It was also viewed as a single phenomenon which was generalisable across situations and rooted in the individual although perceived members of the group exerted considerable influence. The antecedents of morale impacted on the three dimensions outlined above. Its consequences were the zeal with which tasks are undertaken, creativity and engagement. The nomothetic element of the research developed a number of measurement scales, grounded in the qualitative phase. These allowed morale to be differentiated from other phenomena and offered insights into individual and group perceptions of morale and the influence of personality variables. Further quantitative research confirmed the three dimensional structure of the concept. The results of these two phases were then integrated to provide a picture of the phenomenon of morale, differentiate it from other concepts and elucidate its antecedents and consequences. An appraisal of the limitations of the research is also made. Finally the implications of this research for both academic researchers and practitioners are discussed along with suggestions for future research.

The impact of Internet technology on critical thinking is of growing interest among researchers. However, there still remains much to explore in terms of how critical thinking can be fostered through online environments for higher education. Ten years ago, Garrison, Anderson, and Archer (2000) published an article describing the Community of Inquiry (CoI) framework which provided an outline of three core elements that were able to describe and measure a collaborative and positive educational experience in an online learning environment, namely teaching presence (design, facilitation, and direct instruction), social presence (the ability of learners to project themselves socially and emotionally), and cognitive presence (the extent to which learners are able to construct and confirm meaning through sustained reflection and discourse). This dissertation extends the body of research surrounding the CoI framework and also the literature on developing critical thinking in online environments by examining and exploring the extent to which teaching and social presence contribute to cognitive presence. The researcher was able to do this by offering 189 learners enrolled in 10 research methods courses and educational research courses an opportunity to use an innovative online resource (Research Design Learning Resource – RDLR) to assist them in learning about educational research and developing research proposals. By exploring how participants used this resource the researcher was able to gain insight into what factors contributed to a successful online learning experience and fostered cognitive presence. Quantitative and qualitative research approaches (mixed methods) were used in this study. The quantitative results indicated that both social and teaching presence had a strong positive relationship with cognitive presence and that learners generally perceived to have a positive learning experience using the RDLR. The qualitative findings helped elaborate the significant quantitative results and were organised into the following themes: making connections, multiple perspectives, resource design, being a self-directed learner, learning strategies, learning preferences, and barriers to cognitive presence. Future directions for critical thinking in online environments are discussed.

Leadership is important to quality improvement initiatives in healthcare. However, few studies have evaluated leadership interventions to enhance nurses’ use of guideline recommendations in the field of knowledge translation. Purpose: To develop and evaluate an intervention designed to operationalize a leadership strategy composed of relations, change, and task-orientated leadership behaviours, and to examine its influence on nurses’ use of guideline recommendations in home-care nursing. Design: Sequential mixed methods pilot study with post-only cluster randomized controlled trial. Methods Phase I: Intervention Development 1. A participatory approach was used at a community healthcare organization with 23 units across the province of Ontario, Canada. The guideline selected was developed by the Registered Nurses’ Association of Ontario for the assessment and management of foot ulcers for people with diabetes. 2. Integrative literature review, qualitative interviews, and baseline chart audits were conducted. 3. Four units were randomized to control or experimental groups. 4. Clinical and management leadership teams participated in a 12-week intervention consisting of printed materials, interactive workshop, and teleconferences. Participants received summarized chart audit data, identified priority indicators for change, and created a team leadership action plan to address barriers and influence guideline use. Phase II: Evaluation 5. Chart audits compared differences in nursing process and patient outcomes. Primary outcome: eight-item nursing assessment score. 6. Qualitative interviews evaluated the intervention and leadership behaviours. Results: No significant difference was found in the primary outcome. A significant difference was observed in nurses’ documentation of five priority indicators chosen by the experimental groups (p=.02). Gaps in care included: 53%, 76%, and 94% of patients not assessed for ulcer depth, foot circulation, or neuropathy (respectively); 75% and 93% did not receive wound debridement or hydrogel dressings. Receiving data to identify priority indicators for change and developing a leadership action plan were reported as useful to guideline implementation. The experimental group described using more relations-oriented leadership behaviours conducting audit and feedback, and sending reminders. Conclusion: Findings from this pilot study suggest that leadership is a team process involving relations, change, and task-oriented behaviours enacted by managers and clinical leaders. A leadership model is proposed as a beginning taxonomy to inform future leadership intervention studies.

Self-regulation capacity allows individuals to manage their thoughts, feelings, and actions to attain personal goals (e.g., well-being and performance), as well as adjust to their changing social and physical environment (Zimmerman, 2000). Self-regulation as a positive adaptive skill and process has not been examined in relation to well-being in the context of medicine. The purpose of the current study was to examine self-regulation with 37 medical students and 25 supervising physicians to determine whether or not it may enhance well-being and performance, and reduce stress and burnout. A mixed-methods design was used to collect and analyze the data, and findings from the quantitative and qualitative phases were presented in two separate articles. Self-regulation capacity appears to be an important skill that may help both physicians and medical students to meet the demands of the medical profession and maintain an adequate level of well-being and performance in their work and daily life.

The purpose of this doctoral dissertation was to examine the role of program quality within youth sport and understand the relationships between program quality, basic psychological needs support, and psychosocial development. Data were gathered from 33 youth programs across South Eastern Ontario using observations and corresponding field notes, self-report questionnaires from leaders and youth participants, and semi-structured interviews with leaders. The dissertation is composed of five articles. The first article uses structural equation modeling to examine the role of basic psychological needs support in mediating the relationship between program quality and psychosocial outcomes in the youth sport context. Results from this study indicate that both program quality and basic psychological needs play a role in facilitating psychosocial development; however, future research is needed to continue to understand this relationship. The second article presents findings from a sub-sample of the larger study in which a polynomial regression was conducted to examine discrepancies in program quality related to youth volleyball athletes’ needs support. Results indicated that discrepancies existed between researcher- and coach-perceptions of program quality and findings outline how this influences basic needs. The third article represents a mixed-methods examination of program quality and basic psychological needs support within two physical activity-based in-school mentoring programs. Findings from this study revealed a significant difference in program quality across the two programs, specifically related to psychological needs support. Program quality was found to significantly predict needs support within the girls’ program, but not in the boys’ program. Further, field notes were analyzed and practical strategies emerged that were found to help facilitate a quality mentoring program. The fourth article examined the importance of intentionally structuring the youth sport context to facilitate positive youth development across three types of youth programming. Results revealed that intentionally structured programs (both leadership and sport) scored higher on program quality and psychosocial outcomes than non-intentionally structured sport programs. In addition, intentional sport programs scored higher on some elements compared to intentionally structured leadership programs. Finally, the fifth article was a qualitative study that explored youth sport coaches’ perceptions of life skill development. Results indicated that coaches considered life skills to be important, yet believed they were a by-product of sport participation. Coaches also identified challenges associated with using an explicit approach to teaching life skills. Findings from this dissertation provide some of the first empirical accounts of examining program quality within youth sport and suggest that program quality plays an important role in fostering basic psychological needs support and psychosocial development. Moreover, the findings illustrate that there is a need for coach education related to how to structure the youth sport context in order to deliver a high quality program that facilitates psychosocial outcomes.

This thesis will discuss the results of a two-year 90 game study to consider the role violence and aggression plays in competitive minor hockey and its role as a mechanism for injury. The second objective of this thesis was to determine the contextual factors that lead to injury on the ice. Using a mixed methods approach, the study followed three minor hockey teams from the Ottawa-Gatineau region over two sporting seasons. The study found that players are not being injured due to aggressive or violent play but rather players are being hurt within the rules of the game. The contextual factors that were shown to lead to injury included: (1) body-checking, (2) time of the game, (3) player’s body mass, (4) position played and (5) legal plays. Injuries were also broken down by anatomical site (head/neck, upper body and lower body); the upper body was affected by injury most.

Long-term conditions (LTCs) such as diabetes, cardiovascular diseases, respiratory diseases and cancers are recognised as the greatest challenge facing public healthcare systems globally in the 21st century. Healthcare provision for people with LTCs is shifting towards a model that puts patients at the centre of their own care through supported self-care. Self-care support has emerged as a distinct concept in the management of LTCs and is now considered an inseparable component of high quality healthcare provided by healthcare professionals. People with LTCs are regular users of community pharmacy where dispensing and other services provide opportunities for self-care support. While self-care support as a concept has been explored extensively in health disciplines like nursing, medicine and health psychology, there is a paucity of published literature in community pharmacy. The main aim of this programme of work was to explore the place and contribution of community pharmacy in self-care support of LTCs. A preliminary scoping literature review captured and synthesised the overarching components of self-care support of LTCs into a single theoretical framework consisting of collaborative care planning, self-care information and advice, self-care skills support and training, self-care support networks and self-care technology. The research programme of work employed a mixed methods design consisting of three Work Streams. The qualitative arm of the programme consisted of semi-structured interviews with 24 patients with LTCs and 24 community pharmacists in England and Scotland; these informed the quantitative arm, which was a cross-sectional, online survey of 10,000 community pharmacists in England. The survey instrument was informed and developed from the findings of the pharmacists’ interviews in combination with existing literature. Data collection and analysis in the three work streams incorporated the theoretical framework of self-care support. The qualitative data analyses were undertaken thematically, while quantitative data were analysed using a range of descriptive and inferential statistics. Interviews with patients explored their ‘lived experience’ with LTCs and found that self-care was an integral part of daily living; patients engaged in self-care in a variety of ways to attain normality in their lives. Patients used a wide range of resources for self-care support; family/carers, friends and healthcare professionals (mainly doctors and nurses). Patients viewed and used community pharmacy mainly for the supply of prescribed medicines and suggested that community pharmacy played minimal roles in self-care support. The interviews and survey of community pharmacists showed that pharmacists recognised the broad range of activities and principles of self-care. However, in terms of pharmacists’ contributions to self-care support, their perspectives were narrower and focussed on providing information and advice on medicines-use to patients, while other activities such as lifestyle advice were provided opportunistically. They indicated that they were already providing medicines-focussed self-care support through the services available in community pharmacy. The theoretical framework allowed detailed exploration of how community pharmacists operationalised the different elements of self-care support of LTCs. Collaborative care planning was viewed as important but not within the remit of community pharmacy. Self-care information and advice was unidimensional and provided opportunistically and one-off, using the paternalistic biomedical model. Pharmacists valued the roles of patients’ personal communities but were not proactive in signposting to other support networks. Self-care skills training and support and the use of self-care technologies were limited. Barriers to providing self-care support were priority accorded to dispensing activities, the structure of the community pharmacy contract, lack of incentives to provide self-care support and patients’ expectations and lack of awareness of community pharmacy’s role in LTCs management. The theoretical framework of self-care support of LTCs provided novel insights into the perspectives of patients and community pharmacists. The findings highlighted the need for a coherent LTC strategy if community pharmacy is to align with the self-care support paradigm. Recommendations are made for a comprehensive package of care, underpinned by self-care support. A case is also made for incorporating the often ‘unheard’ patient voice into community pharmacy research and interventions.

This thesis analyses the scope for the “self-help” model of rural development to succeed in its broadly stated aims of enabling rural women to advance their social status and enhance their own and/or their family’s livelihoods. The thesis is organised around two key sites of investigation. The first questions the potential for “self-help” to operate within existing social relations - expressed in access to land, other assets and resources (including credit), and in different forms, conditions, and relations of labour. The second questions its potential to intervene in, and potentially overturn, these relations. These questions are embedded in a wider analysis of the ways in which individual and collective attempts to advance living conditions (or at least defend them from deterioration) are defined by historically (re)produced social relations. Analysis is centred on the South Indian State of Andhra Pradesh, where the “self-help” policy approach, now widely replicated as a model for central and federal interventions, is most established. This is a mixed-methods study. It draws on statistical analysis of large-scale secondary survey data, analysis of primary fieldwork, and of government policy documents and other relevant documentation. The thesis engages directly with the philosophical issues this raises, to develop a foundation for the logically consistent assimilation of statistical and “qualitative” methods into mixed methods research. Fieldwork centred on two villages in southern Chittoor district and relied primarily on repeated in-depth interviews with members of four self help groups and, where applicable, their husbands (30 respondents in total). Local officials and programme staff and bank managers were also interviewed. In addition, multi-level logit regression analysis was conducted with two large-scale, complex secondary data sets; the All India National Survey Sample (round 61; schedule 10; 2004/05) and the Young Lives Project Survey (round two; 2005/2006). An innovative weighting procedure was applied to adjust for the latter’s non-random sampling procedure.The findings demonstrate the tensions invoked by state policy emphasising agential action in the absence of due regard for the structural relations within which actions not only take place, but in which the conditions for their possibility and articulation are generated, institutionalised, and reproduced. This situation is exacerbated by unfolding ecological crisis in the fieldwork village sites, problematising the land-based solutions traditionally advocated by the Indian Left. The thesis concludes that Andhra’s self-help programmes can perform a non-trivial ameliorative role in the short-term, but this is undermined by a wider tendency to reproduce and potentially exacerbate ongoing processes of rural differentiation.