Context: Self-learning (i.e., students learning independently) and clinical simulation are essential components in contemporary health professions education (HPE). Self-learning is discussed often, yet the concept is seldom the target of rigorous study. Likewise, simulation modalities are abundant, though educational theory that guides their use in HPE remains elusive. Objectives: This dissertation investigates the effects of directed self-guided learning (DSGL) on novice health professions students’ skill acquisition, retention, and transfer in the context of simulation-based education. The objective is to explore how the combination of external direction and student self-guidance influences: students’ cognitive and metacognitive processes, students’ interactions with the learning environment and available resources, and how students learn in different DSGL contexts. Methods: Three research studies used randomized, controlled experimental designs to address five hypotheses. All studies included a performance assessment one-week after the initial practice session that evaluated skill retention and/or skill transfer. Data analysis employed univariate and multivariate analyses of variance and correlational techniques. Results: Regarding students’ cognitive and metacognitive processes, the data show a relation between DSGL and goal-setting. The results suggest that self-guided students benefit when they are directed to set goals related to performance processes, rather than performance outcomes. Regarding the learning environment, when students are directed to practice on simulators that increase progressively in fidelity (i.e., realism) they self-guide their advancement between those simulators effectively and display successful skill transfer. Finally, self-guided students that controlled their learning progression and learning sequence selected the theoretically most appropriate practice schedule (i.e., progressive learning). Students in this latter group seemed able, surprisingly, to direct their own self-guidance. Conclusions: This dissertation adds support to the hypothesis that self-guided students benefit due to their autonomy in controlling practice conditions to meet their own learning needs. Thus, the question of whether or not DSGL is effective, becomes how best to augment the DSGL experience. The instructional design of elements such as goals lists and task structuring (e.g., progressive increases in simulator fidelity) represent techniques that an educator can use to fulfill the role of director in a student’s SGL.

This thesis seeks to evaluate the International Pediatric Emergency Medicine Elective (IPEME) as a case study of a peace-through-health initiative. Using the reasoning of Scolnik (2006), IPEME is first evaluated in terms of narrow, short-term outcomes and subsequently considered in terms of the greater body of peace-through-health work. A novel evaluation tool was designed to examine change in students’ ethical and professional attitudes over the course of the four-week elective. Supplementary qualitative data was collected to shed light on evaluation findings and provide insight into the advantages and disadvantages of the IPEME curriculum. Ethics and professionalism were defined in terms of the WHO 5 Star Global Criteria for Global Doctors conceptualized by the World Health Organization (Boelen, 1996). This research discusses these findings in light of the study’s limitations and considers their implications for IPEME as a medical elective and for its contribution to the greater body of peace-through-health work.

The world’s understanding of HIV/AIDS is grounded in biomedicine and shaped by cognitive psychology. Both biomedicine and cognitive psychology bonded with historically top-down development mechanisms to create ‘prevention’ strategies that obscured from vision the root causes of the pandemic. Within this hierarchy, bio-medicine and the cognitive psychological conception of human beings silenced indigenous voices and experiences of communities fighting HIV/AIDS. This is most certainly true in the case of Sub-Saharan Africa. This research explores the emergence of the Community Capacity Enhancement – Community Conversations prevention approach that places community dialogue, and the voices of communities, at the forefront of the battle to end HIV/AIDS and deconstruct and challenge the forms of structural violence that hold prevalence rates in their place. Within these spaces, oral traditions, indigenous knowledge, and resistance illustrate new and complex pictures of the viruses’ socio-economic impact and provide new foundations for community generated movements to curb the virus.

This thesis seeks to evaluate the International Pediatric Emergency Medicine Elective (IPEME) as a case study of a peace-through-health initiative. Using the reasoning of Scolnik (2006), IPEME is first evaluated in terms of narrow, short-term outcomes and subsequently considered in terms of the greater body of peace-through-health work. A novel evaluation tool was designed to examine change in students’ ethical and professional attitudes over the course of the four-week elective. Supplementary qualitative data was collected to shed light on evaluation findings and provide insight into the advantages and disadvantages of the IPEME curriculum. Ethics and professionalism were defined in terms of the WHO 5 Star Global Criteria for Global Doctors conceptualized by the World Health Organization (Boelen, 1996). This research discusses these findings in light of the study’s limitations and considers their implications for IPEME as a medical elective and for its contribution to the greater body of peace-through-health work.

The world’s understanding of HIV/AIDS is grounded in biomedicine and shaped by cognitive psychology. Both biomedicine and cognitive psychology bonded with historically top-down development mechanisms to create ‘prevention’ strategies that obscured from vision the root causes of the pandemic. Within this hierarchy, bio-medicine and the cognitive psychological conception of human beings silenced indigenous voices and experiences of communities fighting HIV/AIDS. This is most certainly true in the case of Sub-Saharan Africa. This research explores the emergence of the Community Capacity Enhancement – Community Conversations prevention approach that places community dialogue, and the voices of communities, at the forefront of the battle to end HIV/AIDS and deconstruct and challenge the forms of structural violence that hold prevalence rates in their place. Within these spaces, oral traditions, indigenous knowledge, and resistance illustrate new and complex pictures of the viruses’ socio-economic impact and provide new foundations for community generated movements to curb the virus.

Context: Self-learning (i.e., students learning independently) and clinical simulation are essential components in contemporary health professions education (HPE). Self-learning is discussed often, yet the concept is seldom the target of rigorous study. Likewise, simulation modalities are abundant, though educational theory that guides their use in HPE remains elusive. Objectives: This dissertation investigates the effects of directed self-guided learning (DSGL) on novice health professions students’ skill acquisition, retention, and transfer in the context of simulation-based education. The objective is to explore how the combination of external direction and student self-guidance influences: students’ cognitive and metacognitive processes, students’ interactions with the learning environment and available resources, and how students learn in different DSGL contexts. Methods: Three research studies used randomized, controlled experimental designs to address five hypotheses. All studies included a performance assessment one-week after the initial practice session that evaluated skill retention and/or skill transfer. Data analysis employed univariate and multivariate analyses of variance and correlational techniques. Results: Regarding students’ cognitive and metacognitive processes, the data show a relation between DSGL and goal-setting. The results suggest that self-guided students benefit when they are directed to set goals related to performance processes, rather than performance outcomes. Regarding the learning environment, when students are directed to practice on simulators that increase progressively in fidelity (i.e., realism) they self-guide their advancement between those simulators effectively and display successful skill transfer. Finally, self-guided students that controlled their learning progression and learning sequence selected the theoretically most appropriate practice schedule (i.e., progressive learning). Students in this latter group seemed able, surprisingly, to direct their own self-guidance. Conclusions: This dissertation adds support to the hypothesis that self-guided students benefit due to their autonomy in controlling practice conditions to meet their own learning needs. Thus, the question of whether or not DSGL is effective, becomes how best to augment the DSGL experience. The instructional design of elements such as goals lists and task structuring (e.g., progressive increases in simulator fidelity) represent techniques that an educator can use to fulfill the role of director in a student’s SGL.

In this thesis I will argue that the current predicament we find ourselves in of unsustainable practices can only be addressed through a fundamental shift in the way we view the world and ourselves in it. It is my contention that our most immediate path to achieving this shift is through education. In this thesis I investigate the philosophical basis and justification for education as the impetus for change that will lead to sustainable societies. This inquiry will rethink Freire’s work within our current socio-historical context. Limitations and critiques of Freire’s work will be examined in order to investigate the ability of his work to form the foundation of a paradigm shift towards education that promotes sustainability. The work of C.A. Bowers is used as the basis to interrogate Freire’s work and to re-think some areas to overcome limitations of Freire’s work in his application to Education for Sustainability.

In this thesis I will argue that the current predicament we find ourselves in of unsustainable practices can only be addressed through a fundamental shift in the way we view the world and ourselves in it. It is my contention that our most immediate path to achieving this shift is through education. In this thesis I investigate the philosophical basis and justification for education as the impetus for change that will lead to sustainable societies. This inquiry will rethink Freire’s work within our current socio-historical context. Limitations and critiques of Freire’s work will be examined in order to investigate the ability of his work to form the foundation of a paradigm shift towards education that promotes sustainability. The work of C.A. Bowers is used as the basis to interrogate Freire’s work and to re-think some areas to overcome limitations of Freire’s work in his application to Education for Sustainability.

Canada, like other countries around the world, has health inequities. The literature on social accountability and responsibility urges medical schools to be grounded in the needs of communities to address health inequities. The Canadian professional and regulatory bodies promote the CanMEDS Competencies of which one, the Health Advocate Competency, speaks of addressing community issues. Yet medical schools face challenges actualizing social responsibility and teaching the Health Advocate Competency. Therefore it is important to understand how the teaching of health advocacy and social responsibility is incorporated into the undergraduate curricula of self-defined socially responsible medical schools in Canada. In this study, mixed methods were used beginning with a semi-structured questionnaire administered to undergraduate Course Directors at two medical schools in Canada with a response rate of 74% (n=60). This was followed by a series of open-ended interviews with eleven equity leaders to bring their perspective into the data collection and establish knowledge about frontline intersectional equity work. The major theoretical lens encircling this work was intersectionality which examines historical oppression and how the intersection of gender, race, and class compound health inequities. Questionnaire results made it clear that biomedical ideology and the CanMEDS Medical Expert Competency were privileged in the undergraduate curriculum at the expense of other knowledge such as health advocacy and social responsibility. The objective biomedical discourse ignores or marginalizes important social influences on health which are highlighted by using an intersectional lens. The semi-structured interviews provided rich data about working in an intersectional equity framework highlighting the impact of the intersections of race, gender, class and other identities on health inequities. These interviews also demonstrate the importance of health advocacy in improving health care outcomes and addressing social responsibility. Incorporating intersectionality into previously accepted assessment tools for physicians adds an important dimension to the health care encounter. Explicitly embedding social responsibility and health advocacy in the medical school mission and curriculum is essential to their acceptance. A series of supporting recommendations are offered.

Intubated and mechanically ventilated patients are vulnerable to respiratory tract infections. In response, the Ontario government has recently mandated surveillance and reporting of ventilator-associated pneumonia (VAP). Serious respiratory infections, and the related costs of additional care can be reduced in part, through oral hygiene. However, the literature asserts that oral care is neglected in busy, high-tech settings. Despite these concerns, little research has examined how mouth care happens in the critical care unit. The purpose of this institutional ethnography (IE) was to explore the social organization of mouth care in one critical care unit in Ontario, Canada. As a reflexive and critical method of inquiry, IE focuses on features of everyday life that often go unnoticed. In paying special attention to texts, the ethnographer traces how institutional forces that arrive from outside the practice setting coordinate experiences and activities. Inquiry began in the field with day/night participant observation to better understand the particularities of nursing care for orally intubated patients. Other data sources included reflexive fieldnotes, stakeholder interviews, and transcripts as well as work documents and artifacts. Over time, the analysis shifted from the critical care unit to the larger social context of Ontario’s Critical Care Transformation Strategy. Analysis traced the discursive and translocal social relations that permeate nursing work. Findings revealed a disjuncture between the ideals of VAP prevention and the actualities of mouth care. Tensions and contradictions emerged as nurses described their location within an expansive accountability network: nursing duties now extend beyond oral care to a controversial project of epidemiological surveillance. Patient comfort and safety now rest upon a hidden nursing agenda to overcome limited time, training and tools in oral care. Nurses worried that the effectiveness of preventative oral care was inhibited by technical problems of application that remain uninvestigated and unresolved. As a counterpoint to assertions that oral care is neglected, this study demonstrates how nursing knowledge and agency is obscured. Because international infection-prevention guidelines increasingly endorse oral care, novel research investigating the practice problems nurses encounter is warranted.