Melbourne Medical School Collected Works - Theses

Permanent URI for this collection

Search Results

Now showing 1 - 10 of 29
  • Item
    Thumbnail Image
    Coagulation and inflammation in experimental colitis
    Lust, Mark. (University of Melbourne, 2008)
  • Item
  • Item
  • Item
    Thumbnail Image
    Superantigens and the innate immune response in human sepsis
    MacIsaac, Christopher Mark. (University of Melbourne, 2006)
  • Item
    Thumbnail Image
    Superantigens and the innate immune response in human sepsis
    MacIsaac, Christopher Mark. (University of Melbourne, 2006)
  • Item
    Thumbnail Image
    When General Practitioners (GPs) and patients disagree: impact on the ethics and professional identity of GPs
    Zhao, Crystal Meifen ( 2023-04)
    Patients increasingly present to general practitioners (GPs) with already-formed views of what they feel they need (e.g. antibiotics, X-rays), but which the GPs consider unnecessary. This research explores how GPs experienced and managed these situations in clinical practice. Nineteen semi-structured individual interviews and two focus group interviews were conducted with practising GPs in Victoria, Australia. This study adopted a constructivist and interpretivist methodological approach, and investigated the GPs’ experiences and perspectives of these patient encounters without pre-supposition of what they ought to be doing or thinking. Study methodology privileged the participants’ accounts of their experiences, where they could raise issues that they, rather than the researcher, considered as important. Results showed that GPs found these patient requests for perceived unnecessary care challenging and stressful. They described these patient encounters in two main ways: as interpersonal disagreements with patients that they needed to manage, and also as ethical challenges where they had to work out the right thing to do. Further analysis elucidated that GPs experienced these ethical challenges as a threat that destabilised their professional identity of what it meant to be a good GP. GPs experienced the ethical challenge posed by these patient encounters not as an intellectual conundrum to be worked through dispassionate reasoning, but as a heartfelt threat to their professional identity as good GPs, and how they made sense of themselves and their work. For the GPs, managing these ethical challenges involved working on their sense of professional self, and trying to reshape this identity to mitigate the dissonance between their self-conception of a good GP and what patients expected them to do. My study showed that they struggled to do this work, which was effortful and emotionally stressful for them. This contributed to their sense of stress and distress in these patient encounters and helped explain why GPs found these perceived unnecessary requests so emotionally stressful and difficult. This study provides a fresh perspective on how ethical challenges are experienced and managed in clinical practice. The thesis describes how these patient encounters challenged the GPs’ identity conception of a good GP, the identity work they did in response, and their struggle with this identity work. The research highlights the need to consider the role of professional identity in ethical decision-making when examining ethics in primary care. Importantly, it suggests that effective ethics education and support for GPs require an identity-informed approach, where GPs can be supported to do the difficult and often emotionally stressful identity work. Effective ethics education and support for GPs will benefit not only GPs, but also the patients they care for. This study will also be of interest to medical educators and ethicists involved in the provision of ethics education and support.
  • Item
    Thumbnail Image
    Exploring Contextual Influences on the Ethical Dimensions of Clinical Practice: Perspectives from Physiotherapists in Singapore
    Lim, Audrey Ei-Ping ( 2023-05)
    Ethics is embedded in all aspects of physiotherapy. The importance of ethics in physiotherapy professional practice is reflected in the growing interest in clinical-based ethical issues and the ethical decision-making strategies used by physiotherapists. With emerging evidence of both contextual and individual influences affecting the ethical dimensions of clinical practice, there is a realisation that one cannot address an ethical issue by simply applying a universal set of principles without consideration of context. Context and culture play prominent roles in how we view, comprehend, and construct our world yet the majority of the ethics norms in healthcare practice are grounded in Western theories of ethics, and most of the physiotherapy research on ethics has been done from the Western viewpoint. There is a paucity of the Asian perspective, specifically the East and Southeast Asian regions. This research sought to contribute to current physiotherapy ethics literature by exploring the contextual influences, specifically the organisational and more broadly societal influences on clinical ethical issues and decision-making, as interpreted by physiotherapists in Singapore. Utilising the interpretive description methodological approach, data regarding the types of ethical situations encountered and physiotherapists’ ethical decision-making were collected through in-depth interviews with 42 physiotherapists practising in four different healthcare settings (acute, community, specialised institutions, and private practice) in Singapore. Inductive content analysis was used to analyse the interview data. The empirical findings reflect current literature indicating that individual, organisational and societal context can influence ethical situations, and illustrate context’s critical influencing role in ethical decision-making, as experienced and perceived by physiotherapists in their unique geographical and clinical settings. This research also highlights variations in the way individual clinicians interpret and prioritise contextual influences in their workplaces and social communities, indicating that ethical decision-making cannot be separated from the values and beliefs held by the physiotherapist. In summary, the findings suggest that physiotherapists’ ethical decisions and actions are ultimately determined by the dynamic interaction between individual characteristics and contextual influences. Finally, physiotherapists practising in the Singaporean context prioritise the maintenance of harmonious relationships and pragmatic considerations as important contextual influences in their ethical practice. By focusing on the organisational and societal influences on the ethical dimensions of physiotherapy practice in the Singaporean context, this research contributes to the body of ethical literature from the Asian perspective. Identifying the contextual factors that influence physiotherapists’ moral agency will allow the local physiotherapy community to understand both the facilitators and barriers to ethical practice. This research provides the impetus to move beyond universal moral theories and code of conduct, and to consider the workplace context as an important inclusion in ethics education and support for clinicians. The empirical data from this research can also inform the development of ethics curricula to ensure that universal ethical principles are situated within the realities of clinical practice. Locally relevant and realistic ethical case studies will better enable students to recognise and address these situations.
  • Item
    Thumbnail Image
    Guiding educators in learner-centred feedback: designing, testing and refining the Feedback Quality Instrument
    Johnson, Christina Elizabeth ( 2020)
    Feedback is important but problematic in the health workplace. The aim of this research is to promote quality feedback discussions that enhance learner outcomes. This thesis reports the process of developing, testing and refining an instrument to guide and systematically evaluate an educator’s role in quality face-to-face feedback in clinical practice. It is underpinned by social constructivism, and uses a multiphase mixed methods design to achieve the research objective. The research was conducted in three phases. Phase 1 comprised a systematic review and meta-analysis to summarise the empirical evidence available concerning the impact of face-to-face feedback on workplace task performance involving health professionals. Phase 2 focused on the development of a provisional feedback instrument. An extensive narrative literature review identified the distinct elements of an educator’s role with the potential to influence learner outcomes. These elements were then operationalised into corresponding observable educator behaviours and refined in collaboration with an expert panel using a Delphi process. This resulted in consensus on a set of twenty-five descriptions of educator behaviours that manifest quality feedback, which constituted a provisional instrument. Phase 3 involved refining the provisional instrument to create the Feedback Quality Instrument using quantitative and qualitative analyses. Thirty-six videos of authentic clinical feedback discussions were collected. Six raters independently administered the provisional instrument to evaluate educator behaviours seen in the videos, compared with recommended behaviours in the provisional instrument, using a Likert scale: 0 = not seen, 1 = done somewhat, 2 = done consistently. This enabled usability testing and generated 174 sets of ratings data. Quantitative analysis of these ratings data were used to describe a) how commonly each recommended behaviour was demonstrated by the group of educators and b) variation across educators’ practice, which was achieved by describing how many of the recommended behaviours each individual educator demonstrated. This afforded rare observational insights into contemporary feedback interactions, confirmed a gap between recommended and workplace practice, and indicated priorities for professional development initiatives. These ratings data were also used for psychometric analysis of the provisional instrument using multifaceted Rasch model analysis and exploratory factor analysis. In addition, using thematic analysis, qualitative analysis of the video data was performed to explore two key emergent phenomena 1) the potential for promoting learners’ own evaluative judgement and 2) ways in which educators could help to cultivate psychological safety with learners within feedback conversations. The qualitative analyses further clarified desirable educator approaches to feedback, enabling refinement of the instrument and addressing gaps identified during psychometric testing. Finally, the provisional instrument was refined, informed by the usability testing, psychometric testing, qualitative analysis, and foundational literature and theory. This resulted in the Feedback Quality Instrument (FQI), ready-for-use in clinical practice. The FQI includes 25 items, grouped into five domains: set the scene, analyse performance, plan improvements, foster learner agency, and foster psychological safety. These domains characterise five core concepts underpinning quality feedback identified by exploratory factor analysis. The items offer practical guidance for clinicians in fostering learner-centred feedback in collaboration with learners by describing behaviours that engage, motivate and enable a learner to improve. The instrument also provides a platform for future research investigating the impact of specific components of feedback on learner outcomes in the clinical workplace. This PhD program of research leading to the FQI includes four published articles, one article under submission and one published book chapter.
  • Item
    Thumbnail Image
    Overseas Qualified Nurses’ intercultural communication: An exploration of perspectives, experiences, and practices
    Philip, Jalaja Susan ( 2020)
    Overseas qualified nurses (OQNs) from non-English speaking backgrounds comprise a significant proportion of Australia's health workforce. While numerous studies have identified that OQNs encounter intercultural communication challenges and dissonance, there has been little exploration into nurse educator perspectives and few observational studies of OQNs’ intercultural communication with healthcare teams and patients. The aim of this research was to examine OQNs’ perspectives, experiences, and intercultural communication practices. The overall study design was qualitative, using semi-structured interviews and participant observation with thematic and discourse analyses, respectively. The theoretical underpinnings and principles of this research are informed by frameworks of intercultural communication, Communities of Practice, and patient-centred communication. This research comprises three studies: an interview study with nurse educators; an interview study with OQNs; and an observational study with OQNs. The first study comprised interviews with 12 nurse educators of the pre-registration course, revealing the areas and causes of communication challenges encountered by OQNs, as well as engagement strategies to address these challenges. The second study involved interviews with 21 OQNs to explore their intercultural communication experiences. The OQNs’ transition process evoked uncertainty due to concerns about language and cultural and contextual issues, leaving OQNs feeling like uncertain novices, even for those working in Australia for several years. Findings of the two interview studies informed the design of the third study, which was observational and investigated inter-professional, intra-professional and nurse-patient communication. Participants were 13 OQNs who were shadowed for a 2.5 to 3 hr period during their clinical work at a public teaching hospital. Linguistic evidence of inter-professional and intra-professional communication from the observational study showed limited casual interactions, such as small talk between OQNs and other members of the team. This lack of informal interactions can contribute to a lack of team cohesion and negatively impact open team communication. Patient-centred communication was achieved to varying degrees. The findings provided evidence of positive rapport building strategies, including non-verbal communication that assisted and countered communication hindered by lack of fluency, vocabulary and accents. Brevity in information provision to a team member or missed opportunities in offering advice or reassurance to a patient or a family member are features that impeded desirable outcomes in team communication and patient-centred communication. Collectively, this research makes an original contribution to existing knowledge by revealing patterns of OQNs’ intercultural communication through interactional evidence from the observational study with patients and the healthcare team. In addition, the combined reflections and evidence from educators, the OQNs, and the observed interactions add to existing literature in terms of the interplay of language features on comprehension and effective communication, and also contextualise this interplay in the conduct of clinical work. These findings provide evidence that could enable OQNs to gain insight into their practices, and the local team members to reflect on their role in effective team communication. Another application of this research is its potential contribution to inform the national accreditation body for nursing, curriculum developers, and employers of the significance of developing intercultural communication competence for OQNs and healthcare teams.
  • Item
    Thumbnail Image
    Assessor grades and comments: private thoughts and public judgements
    Scarff, Catherine Elizabeth ( 2020)
    Assessment of medical trainees’ performance in the workplace aims to provide them with accurate and meaningful information and guidance on their learning and developing competence. However, in practice, such goals aren’t always achieved. Sometimes assessors find it difficult to deliver clear and consistent assessment messages to a trainee, especially when the information or judgement they have to give is negative. While this can occur for many reasons, including disagreement with or uncertainty about assessment processes, the MUM effect — the widespread human tendency to keep mum about undesirable messages — may also have relevance for the situation. With reference to this framework, this thesis explores how and why reluctance to deliver negative assessment messages manifests in a medical specialty training setting in Australia. Literature reviews on the MUM effect and trainee perspectives of assessment messages informed the design of a mixed methods study which explores the MUM effect in this context. The study involved four parts: - a questionnaire study of assessor self-reports of discomfort and MUM behaviours in assessment; - a questionnaire study of trainee perspectives of MUM behaviours by their assessors and their views of the clinical performance assessments; - a review of a sample of previously submitted assessment forms comparing the messages sent by numerical ratings with those by written comments; and - an interview study of assessors to further understandings of their experiences with and perspectives of these assessment formats. The findings show that reluctance to deliver negative assessment messages — which can result in failure to give feedback, failure to fail and grade inflation — are real and continuing issues in medical education. The MUM effect offers one explanation for their persistence, despite the many methods which have been employed to date to address them. The study shows how the MUM effect permits an expanded view of the problem and that assessor reluctance can lead to behaviours beyond the commonly reported failure to fail and grade inflation. These include behaviours such as delay, avoidance and distortion of assessment information. Further, the results show that reluctance can affect the comments part of an assessment in addition to the ratings, which have been the main focus to date. This study reveals the many pressures and dilemmas that assessors face in their role and in particular, that the amount of discomfort they experience can potentially affect their assessment behaviours and result in MUMing. This work also shows that trainees are aware that their assessors sometimes keep mum, meaning the judgement delivered may differ from the assessor’s private thoughts on their performance. Potential solutions are seen to be multifactorial and include addressing perceptions about “failure” in clinical performance assessments and the responsibility that assessors feel for the assessment decisions.