Previous research has established a consensus that in-hospital adverse events are ubiquitous, cause significant harm to patients, and have important financial consequences. However, information on the extent, consequences and costs of adverse events in Canada is limited. For example, there is, as yet, no published study that has investigated the costs of adverse events in a Canadian context. This dissertation aims to redress this situation by providing Ontario-based estimates of the impact of eleven nursing sensitive adverse events on cost, death, readmission, and ambulatory care use within 90 days after hospitalization. This dissertation also aims to contribute more broadly to the patient safety literature by quantifying the impact of diagnostic coding error in administrative data on estimates of the excess costs attributable to adverse events. Given the increasing importance of these estimates in Canada and elsewhere for hospital payment policy and for assessments of the business case for patient safety, this is an important gap in the literature. Each of the adverse events was associated with positive excess costs, ranging from $29,501 (metabolic derangement) to $66,412 (pressure ulcers). Extrapolation from the study hospitals yielded a provincial estimate of $481 million in annual excess costs attributable to the adverse events, which represents 2.8 percent of Ontario’s total hospital expenditures. Several of the adverse events were also associated with significant excess rates of death, readmission, and ambulatory care use. These results suggest that there are economic as well as ethical reasons to improve patient safety in Ontario hospitals. Estimates of adverse event costs were highly sensitive to coding error. The excess cost of adverse events is likely to be significantly underestimated if the error is ignored. This finding, coupled with the observation that the likelihood of error is ignored in most studies, suggests that previous assessments of the business case for patient safety may have been biased against the cost effectiveness of patient safety improvements. Furthermore, the observed extent of institutional level variation in adverse event coding indicates that administrative data are an inadequate basis for adverse event payment policies or for public reporting of adverse event rates.

Purpose: To describe patient & tumor characteristics among rectal cancer patients in Nova Scotia, to determine factors associated with permanent colostomy and oncologic outcomes and to determine the relationship between surgeon knowledge and oncologic outcomes.Methods:The Provincial cancer registry identified new rectal cancer patients from in Nova Scotia. A comprehensive review of inpatient, outpatient and cancer center medical records was used to assemble the cohort. Surgeon knowledge was assessed using a survey with questions pertaining to rectal cancer care.Results: Patient & tumor characteristics were similar between hospitals providing rectal cancer care. Patients treated by high volume cancer center surgeons are less likely to undergo a permanent colostomy or have a local recurrence compared to patients treated elsewhere. Patients treated by surgeons with a high survey score have improved clinical and oncologic outcomes.Conclusions: There is an opportunity to improve rectal cancer care in Nova Scotia.

At the time of this study (2009) the role of the nurse practitioner (NP) was new to the province of British Columbia (BC). The provincial government gave the responsibility for implementing the role to health authorities. Managers of health authorities, many of whom were unfamiliar with the role, were responsible for identifying the need for the NP role, determining how the NP would function, and gaining team members’ acceptance for the new role. The purpose of the study was to explain the process of NP role implementation as it was occurring and to identify factors that could enhance the implementation process. An explanatory, single case study with embedded units of analysis was used. Three primary health care (PHC) settings in one health authority in BC were purposively selected. Data sources included semi-structured interviews with participants (n=16) and key documents. Propositions and a conceptual framework developed from the review of the literature guided the study. Key components of the framework were the concepts of intention, involvement and acceptance. The results demonstrate the complexity of implementing the NP role in settings unfamiliar with it. The findings suggest that early in the implementation process and after the NP was hired, team members needed to clarify intentions for the role and they looked to senior health authority managers for assistance. Acceptance of the NP was facilitated by team members’ prior knowledge of either the role or the individual NP. Community health care providers needed to be involved in the implementation process and their acceptance developed as they gained knowledge and understanding of the role. Although relatively new in their roles, NPs were enacting, to some degree, all competencies of the role, as defined by College of Registered Nurses of BC. The findings suggest that the interconnectedness of the concepts of intention, involvement and acceptance influences the implementation process and how the NP is able to function in the setting. Without any one of the three concepts not only is implementation difficult, but it is also challenging for the NP to fulfill role expectations. Implications for research, policy, practice and education are discussed. / case study research

Generalized estimating equations (GEEs) are commonly used in the modelling of correlated data. However, in the presence of informative cluster sizes, estimates obtained using GEEs may be biased. In order to correct for this bias a weighted GEE may be used. Previous research has extended the use of weighted GEEs to a longitudinal setting but requires that cluster sizes remain constant over time. In this thesis, two new weighting schemes are investigated to allow for valid parameter estimation in a longitudinal setting where cluster sizes are informative and may change over time. Specifically, this thesis considers weighting by the inverse of the time-dependent cluster size, and by the total number of observations for a given cluster. Through Monte Carlo simulation, the performance of traditional GEEs, GEEs under previously proposed weighting schemes, and these two new models are compared. Results of these studies show that weighting by the total number of observations results in unbiased parameter estimates with excellent coverage.

Abstract The Swedish National Curriculum for Upper Secondary School states that English should be taught essentially in English. The aim of this study was to discuss the use of Swedish in the upper secondary English classroom with regard to building teacher-student relations and learning outcomes. A hypothesis was articulated, claiming that judicious use of Swedish in the English classroom would help establish teacher-student relations, which would benefit learning outcomes. The study focused on students’ attitudes on the use of Swedish in the English classroom, on the importance of student-teacher relations with regard to learning outcomes, and on the effect English has on building relations and learning outcomes. The material for the study was obtained from a student questionnaire with mixed multiple choice and essay questions. Results showed that most students preferred the inclusion of Swedish in English education and considered it beneficial to their learning. Despite students’ opinion, the national curriculum’s guidelines, and the line of current modern language research, a rather large part of students’ teaching appeared to be conducted in English only. Results furthermore showed that students considered the relation to their teacher more important for their learning outcomes than the language used by the teacher in class. An English-only requirement was experienced as inhibiting by a small majority of students with regard to building relations. It was concluded that Swedish could be seen as an useful instrument when forming teacher-student relations in the English classroom, which raised the thought that the national curriculum should, instead of restricting the amount of Swedish, stress when and how the use of Swedish is fruitful. This study is important as it shows how Swedish could be a useful tool in the specific environment of the English classroom, which calls for a different approach to English language learning than is supported in the national curriculum.   Key words: English, L1/L2, learning outcomes, relational pedagogy, socialization, student, teacher

The General Medical Council now requires that all new medical graduates in the United Kingdom should be able to ‘function effectively as a teacher’. This thesis explores multiple perspectives on what this means, and the implications for medical student learning in relation to teaching. There is a lack of existing literature exploring how those involved in the undergraduate medical curriculum conceptualise teaching or what it means to function effectively as a teacher. There is also a lack of literature on what teaching recent medical graduates undertake, and what, if any, learning outcomes in teaching they and other key stakeholders think should be core for the undergraduate medical curriculum. To address these gaps in the literature, original data were gathered using 1) a Delphi study with eighteen experts in medical education, 2) semi-structured interviews with nineteen recent medical graduates, and 3) focus group interviews with twelve final year medical students. The three data sets were analysed individually, compared, then synthesised with the existing literature. All three participant groups articulated a wide range of conceptions of teaching, with considerable variation both within and between groups. The great majority thought that all medical students should learn about teaching as part of the undergraduate medical curriculum. Almost all of the recent graduates and medical students viewed teaching as part of the role of junior doctors working in the UK, although only two thirds of the recent graduates said they saw themselves as teachers. The recent graduates reported having delivered a wide range of teaching in their first year of work as junior doctors, and this correlated well with the range of teaching medical students reported having received from junior doctors. Teaching undertaken by recent medical graduates could be grouped into three broad categories: informal opportunistic teaching, semi-formal pre-arranged teaching, and formal organised teaching. A total of 153 learning outcomes in teaching were suggested and rated by the expert Delphi panel in terms of how appropriate they were for UK undergraduate medical curricula. Many of the graduates and students also suggested some learning outcomes in teaching before rating the 153 learning outcomes arising from the Delphi. All three groups indicated that they thought most of the 153 learning outcomes in teaching should be core for all UK undergraduate medical curricula, although there was some variation within and between groups. The majority of these learning outcomes have not been previously suggested in the literature for UK undergraduate medical curricula, but are consistent with literature on teaching competencies expected of more senior doctors. This thesis offers new insights on what teaching means to experts in medical education, recent medical graduates and current students, comparing these between groups and with the educational literature. It also offers multiple perspectives on core learning outcomes in teaching for UK undergraduate medical curricula, and greater understanding of the teaching undertaken by UK medical graduates. This thesis could help those responsible for undergraduate medical curricula to prioritise, refine and exemplify detailed learning outcomes in teaching, ensuring their graduates are more prepared for practice. It will also be of interest to policy-makers, programme directors, teachers, students, junior doctors, administrators and academics involved in medical and allied healthcare education. It is hoped that this thesis will encourage stakeholders to reflect on what teaching means to them, the role of junior doctors as teachers and the implications of learning about teaching as part of the undergraduate medical curriculum, leading to greater engagement, scholarly debate and research in this area. This in turn may lead to doctors delivering better quality teaching, to students and trainees in medicine and other disciplines receiving better teaching, and consequently to patients experiencing better healthcare.

The purpose of this study is to more clearly understand what student' experience while involved in service-learning courses. Moreover, I sought to identify the relationships among service-learning, the outcomes typically attributed to it, and student engagement according to Naturalistic Inquiry methodology (Lincoln & Guba, 1985) and quantitative data from the Australasian Survey of Student Engagement (2009-2010) in two different upper-division courses at the University of Canterbury in New Zealand during the second semester of the 2009 academic year. One class approached service-learning in an addendum/add-on type of approach (Approach I service-learning), while the other course used a more fully-integrated approach (Approach II service-learning). The theoretical framework offered by the philosophy of experiential education (Dewey) and the theories of experiential learning (Kolb), transformative learning (Mezirow), and student engagement (Kuh) combine to serve as the lens through which service-learning was initially viewed in this study. This framework provided the initial structure by which this study was facilitated and the relationship between service-learning and its typically attributed outcomes could be observed and better understood within a New Zealand tertiary environment. The student experiences within Approach I and II service-learning served as sources for pursuing a greater level of sophistication and understanding of how these experiences influence the relationships of service-learning and ultimately how service-learning influences student engagement. Such an investigation is relevant to New Zealand tertiary teachers, researchers, and leaders, who are interested in creating conditions that engage students in learning while developing students personally and involving them within the local community. For transferability purposes, the goal of this study is to provide enough “thick description” (Lincoln & Guba, 1985, p. 125) in the case of each approach to service-learning so that educators from New Zealand and the rest of the world can find meaning, value, and direction. Quantitative findings from this study clearly demonstrated a statistically significant shift in student engagement benchmarks in both approaches to service-learning (3 of 6 AUSSE benchmarks in Approach I service-learning and 6 of 6 AUSSE benchmarks in Approach II service-learning). Qualitative data provided the means to suggest why these significant shifts occurred and illuminated the complexity of the student experience within service-learning environments. Qualitatively, both approaches to service-learning shifted the context of what it meant to be a student in a classroom. The following themes symbolize the different experiences and demonstrate ways teachers can best engage both eager and reluctant learners: different experiences-providing opportunities for growth; consistently being a part of something-internal/external to university; active-learning through experiencing and thinking for yourself; worthwhile, intrinsic-due to helping community organisations. Considering the effects of service-learning on engagement have been relatively un-researched in New Zealand higher education and further inquiry into the pedagogical consequences has been warranted, the implications may provide insight into the development of service-learning in higher education for New Zealand, Australasia, and potentially, the world.

Employment relations literature is concerned with what is exchanged between the employer and the employee via an employment contract, a social contract or a psychological contract, with perceived mutual obligations (Rousseau, 1995; Capelli, 1999; Kalleberg, 2001). The psychological contract finds its foundation in the perceptions of the employee, that is, what the employee believe the employer has offered the employee in terms of their work relationship and the social contract refers to the expectations and obligations employers and employees have for their work and the employment relationship (Grahl, & Teague, 2009). The new employment contract differs from the old employment contract in that it is largely informal and even unwritten (Gilbert, 1996). This is in line with the new trend of business management as used by people-driven world-class organisations with a globalised focus (Gilbert, 1996). A research need exists to examine the potentially different or redundant effects of promises and expectations on the development of the obligations that are perceived to constitute the employment, the social and the psychological contracts (Martocchio, 2004; Shore, Tetrick, Taylor, Coyle-Shapiro, Liden, McLean-Parks, et al. 2004). The primary objective of this research is to investigate the relationship between the social- and the psychological contracts of private security employees (N=217) in the Vaal Triangle in terms of employability, job insecurity, job satisfaction, life satisfaction and intention to quit. This study is submitted in article form. The research method for each of the two articles consists of a brief literature review and an empirical study. Factor analyses, as well as Cronbach alpha coefficients were computed to assess the reliability of the research. Validity, Pearson product moment correlation coefficients as well as regression analysis were utilised to examine the relationship between the constructs employed in this research. The Employment Contract Scale (ECS) was also utilised as a research instrument, as the questionnaire-method proves to be largely reliable. Reliability analysis confirmed sufficient internal consistency of the subscales. The observed correlations were found to be comparable with the values reported in previous research by Edward and Karau (2007). By using multiple regression analysis, it was established that by investigating the relationship between the social- and the psychological contracts of private security employees (N=217) in the Vaal Triangle in terms of employability, job insecurity, job satisfaction, life satisfaction and intention to quit (the primary objective of this research) that job satisfaction and intention to quit predicted the social contract and that job satisfaction and life satisfaction predicted the psychological contract. No relationship however exists between employability, intention to quit and the psychological contract. Recommendations are advanced for future research. / MA (Labour Relations Management) ,North-West University, Vaal Triangle Campus, 2013

The aim of this study was to outline the importance of Junior Traffic Training Centres in both primary and secondary schools. This would aid the effective integration of Traffic Safety Education in the school curriculum within outcomes-based education. The primary objective of this research was to determine the ways in which Junior Traffic Training Centres at schools are instrumental in the development of knowledge, skills and attitudes of learners towards safe participation in traffic environment. This research was conducted by means of a literature study and an empirical investigation through a questionnaire and observations. Investigation focused on learners from three schools, namely Maheelo Primary School (a farm school at Hartbeesfontein), Gaenthone Secondary School (a semi-rural school in Tigane Township near Hartbeesfontein) and Phaladi Combined School situated in Ikageng Township. It was found that more emphasis should be placed on pedestrian education. Learners should be taught traffic safety from pre-school, with the help of Junior Traffic Training Centres. Ten recommendations are made in Section 7.5. These include more training in Traffic Safety Education and that focus must be placed on disadvantaged areas; that government should avail trained teachers in Traffic Safety Education; and that schools must have access to Junior Traffic Training Centres. This study is of significance to the North West Province and the South African society because each day we lose learners through road accidents. This does not only cost the government money but is also painful to all of us. This study maintains that teaching our learners road safety education could contribute towards overcoming this situation. / Thesis (M.Ed.)--North-West University, Potchefstroom Campus, 2004.

The formalized nurse practitioner (NP) role in British Columbia is relatively new with the majority of roles implemented in primary care. The majority of primary care is delivered by physicians using the fee-for-service model. There is a shortage of general practitioners (GP) and difficulties with recruitment and retention, particularly in rural and remote locations. The uptake of the primary care NP role has been slow with challenges in understanding the extent of its contributions. This study was to identify the impacts and outcomes associated with the NP role in collaborative primary care practice. Multiple case studies where NPs were embedded into rural fee-for-service practices were undertaken to determine the outcomes at the practitioner, practice, community, and health services levels. Interviews, documents, and before and after data, were utilized to identify changes in practise, access, and acute care service utilization. The results showed that NPs affected how care was delivered, particularly through the additional time afforded each patient visit, the development of a team approach with interprofessional collaboration, and a change in style of practise from solo to group practise. This resulted in improved physician job satisfaction. Patient access to the practice improved with increased availability of appointments and practice staff experienced improved workplace relationships and satisfaction. At the community level, access to primary care improved for harder to serve populations and new linkages developed between the practice and their community. The acute care services experienced a statistically significant decrease in emergency use and admissions to hospital (p= .000). The presence of the NP improved their physician colleagues desire to remain in their current work environment. This study identified the diversity of needs that can be addressed by the NP role; the importance of time to enhance patient care, and its associated benefits, especially in the fee-for-service model; the value of the NP’s role in the community; the acceptance of the clinical competence of NPs by their physician colleagues; the outcomes generated at the practice level in terms of organizational effectiveness and service provision; and substantiated the impact of the role in improving primary care access and reducing acute care utilization. / Graduate