Thesis (MPhil)--Stellenbosch University, 2011. / ENGLISH ABSTRACT: Background: The theoretical / cognitive component of ethics and professionalism teaching to undergraduate medical students at Stellenbosch University (SU) is well developed, but a concern exists about the need for teaching and assessment of clinical ethics and professionalism on ward rounds. Some teaching does take place during clinical rotations in the form of role modelling as part of the hidden curriculum. Opportunities should be created for explicit teaching of ethics and professionalism beyond the hidden curriculum. Assessment of the cognitive component of ethical and professionalism occurs, but assessment of clinical ethics and professionalism during clinical rotations remains a challenge. Methods: This was a non-experimental study and included three subgroups of undergraduate medical students in their clinical years as well as a random sample of educators involved in clinical training. Questionnaires were distributed to the students and educators. This was followed by focus group interviews among the students. Results: A majority of the students (88%) had indicated that they had experienced ethical and professional dilemmas while working in the wards or during ward rounds. The main dilemmas revolved around inadequate consent processes, lack of confidentiality and privacy, disrespect for patients, poor communication and students being expected to perform tasks they were not trained for. An average of 64% of students indicated that ethical and professional issues were not discussed during the clinical rotations in hospitals. Seventy-eight percent of students indicated that they did not feel free to discuss their own feelings or beliefs on ward rounds. All of the educators felt that there was a need for increased teaching and assessment of the medical students during their clinical rotations. Conclusions: Deliberate opportunities need to be created for teaching ethics and professionalism on clinical ward rounds. This could be a shared responsibility between the clinical departments with continuous input throughout the clinical years of study. Strong institutional support and commitment are necessary to make the teaching sustainable and successful. Structured opportunities need to be developed where students can discuss ethical and professional issues in a safe environment. Further research is needed for the development of an appropriate curriculum and assessment tools. / AFRIKAANSE OPSOMMING: Geen opsomming

This study originates out of my experience as an environmental educator working within business and industry in Zimbabwe and South Africa. It is motivated by my observation that, despite much environmental rhetoric and training, environmental education in industry rarely leads to significant advances towards environmental protection. I assume that the problem of the mismatch between rhetoric and action involves both semiotic and non-semiotic components and therefore, after a thorough exploration of my methodological options, I adopt a qualitative transdisciplinary textual analysis of relevant documents using Fairclough’s Critical Discourse Analysis and Bhaskar’s Dialectical Critical Realism, with some insights taken from Bhaskar’s more recent concept of Meta-Reality. My main conclusions from the study indicate that causally efficacious philosophical mistakes, relating to theories of structure/agency and theories of epistemology, are an important aspect of the problem being considered. Specifically, I demonstrate that these mistakes function to buttress ideology and its attendant contradictions which in turn function to provide the preconditions that maintain inequalities and poor environmental practice in business and industry. Prior and current events, such as climate change and the trend towards globalisation, the ‘free market economy’ and psychological characteristics of the author, relevant to the problem, are also important. In line with Bhaskar’s emancipatory aim for explanatory critique, I end with tentative recommendations for a re-imagined environmental education for business and industry which require (un)action. Consistent with my methodological choices, my recommendations have a (qualified) universal application, despite my focus on texts from South Africa and Zimbabwe. My recommendations are summarised below: • there should be consistency between theory and practice such that performance contradictions are avoided; • we should not act from a fear of survival based on past, no longer relevant experiences (e.g. from childhood) as this is unlikely to be an adequate base for present actions; • we should avoid voluntarism by acting with the resources at our disposal, based on a true understanding of our strengths and weaknesses and our own specificities; • we should avoid assuming the stance of the ‘victim’ by refusing to blame other agents or circumstances, without distorting or underestimating the causal efficacy of those agents or circumstances (related to avoiding voluntarism, whilst nevertheless not resorting to determinism either); • we should direct our action towards the abolition of inequalities and master-slave relationships (related to the avoidance of performance contradictions); • we should act from the position of epistemological humility, rather than from the position of epistemological privilege; • we should consider action as ‘shedding’ based on an understanding of the Transformational Model of Social Activity (TMSA); and • we should consider learning to be ‘shedding’ based on the necessity of (un)knowledge, or ignorance, as a requirement of arriving at relatively new knowledge. This study is also a contribution to contemporary methodological discussions relevant to Critical Discourse Analysis in that it extends these discussions to include psychoanalytical (as well as the more familiar phenomenological and ideological) depth explanations of lived illusion. Furthermore, this study is an experimental attempt to apply the concept of ‘meta-reflexivity’ in Critical Discourse Analysis.

Indiana University-Purdue University Indianapolis (IUPUI) / Background: Recent literature on medical professionalism claims that self-awareness and the ability to reflect upon one’s experiences is a critical component of professionalism; however there is a paucity of empirical evidence to support this claim. This study employed a mixed methods approach to explore the utility of reflective writing and self- and peer assessments in explaining professionalism lapses among medical students. Methods: A retrospective case-control study was conducted using students from Indiana University School of Medicine (IUSM) who had been disciplined for unprofessional behavior between 2006-2013 (case group; n=70). A randomly selected control group (n=230) was used for comparison. Reflective ability was assessed using a validated rubric to score students’ professionalism journals. Mean reflection scores and assessment scores were compared using t-tests. Logistic regression analysis was used to determine the impact of reflection scores and self- and peer assessment scores on the likelihood of having been disciplined for unprofessional behavior. Subsequent qualitative analysis further explored when and how students learned professionalism during their clinical experiences. Results: The study found that students in the case group exhibited lower reflective ability than control students. Furthermore, reflective ability was a significant factor in explaining the odds that a student had been cited for professionalism lapses. There were no differences in self-assessment scores between the two groups, but students in the case group had significantly lower peer assessment scores than control students. Peer assessment scores also had the greatest influence on the odds that a student had been cited for professionalism deficiencies during medical school. Qualitative analysis revealed that students learn professionalism from role models who demonstrated altruism and respect (or lack thereof). Conclusions: These findings suggest that students should be provided with guidance and feedback on their reflective writing to promote higher levels of reflection, which may reduce the number of students who are cited for professionalism lapses. These findings also indicate that peer assessments can be used to provide students with insightful feedback regarding their professional development. Finally, role models have a strong influence on students’ professional development, and therefore must be cognizant of the implicit messages their behaviors convey.