8.3 ETHICAL ENACTMENT in POLICY DESIGN, CURRICULUM REORGANISATIONS
8.3.3 Ethical Enactment in Curriculum Re-organisation
The transdisciplinary approach to curriculum integration is boundary-less, uniting various disciplines, by organizing teaching and learning in a pragmatic context, consisting of real-world complexities, wherein meaning is constructed and emerges (Alonge et al., 2016). However, according to Alonge et al. (2016), in this 4IR, fundamental diverse approaches to teaching and learning need to be acquired.
A variety of new technologies are uniting the physical, digital and biological ecospheres, impacting all disciplines, economies and industries, with artificial intelligence (Stefanelli, 2001). Even concepts
about what it means to be human are being challenged (Effoduh, 2016). Notions of using familiar theories, a narrow set of psychological assumptions and conventional approaches in planning health science curricular and teaching pedagogy, necessitate rethinking (Peters et al., 2011). Likewise, core beliefs of expert educators need to be reviewed and transformed, with the intention of creating a new paradigms of teaching and learning (Howard et al., 2009).
Recurrent disequilibrium in the health ecosystem, complex organisational and psychosocial dynamics and impact of artificial intelligence on health science education demand critical thinking and a systemic approach to health science education. Systemic learning commences with constructive dialogue among educators, health science learners and policymakers, in addition to the ability of systemic stakeholders to suspend assumptions and enter into honest collective systemic thinking (Buehler, 2016).
The use of systems thinking in health science teaching and learning creates the possibility for us to understand complex problems and generate more creative and sustainable solutions to inadequately perform health systems globally. In a study conducted by Calhoun et al. (2008, p. 3), health educators concluded that “systems thinking should be a core domain in public health curricula”. Gebbie et al.
(2008) determined it as a core competency of health research training. For example, systems thinking can resolve, emerging public health epidemiological factors resulting from complex system of spatio- temporal interactions at the biological, socio-behavioural and economic levels. To address these complex epidemiologic conditions like chronic diseases, infectious diseases, HIV, TB, mental health problems, obesity, nutritional imbalances, smoking, or alcohol and substance abuse, public health professionals need be trained in systems thinking to enable them to design effective interventions and maximize positive health outcomes, while minimizing unintended negative consequences. A case in point of interventions that were designed by public health professionals, using systems thinking expertise were the high-impact prevention and control programmes for polio eradication (Thompson, 2008) and smoking cessation (Levy et al., 2010). As public health professionals use their systems thinking expertise and collaborate with traditional training educators with reductionist approaches to teaching causal-effect relationships, integral training in planning and implementing public health solutions results.
Similarly, through effective changes at several sub-system interactions, improved health outcomes emerge (Frenk et al., 2010). Essentially, contemporary health practice approaches in health teaching curricula, require fundamental transformation, which becomes inclusive of multi-factorial chronic diseases experts who collaborate with numerous disciplines and sectors. According to Frenk et al.
(2010), academic disciplines such as organisational management, social sciences, and institutional
analysis and systems sciences are emerging as vital domains in an integral approach to teaching and learning in health science curricula.
At the WEF (2018), emphasis on collaboration among multiple disciplines and sectors resulted in cost savings by the use of new technology-driven approaches, thereby releasing funds for other healthcare system efficiencies. Illustrations of how globally the cause of escalating morbidity through
preventable chronic diseases like diabetes can be promptly and accurately diagnosed and monitored by wearing non-invasive devices that will continuously monitor vital signs, were also highlighted.
This collection of patient personal data can reduce the number of medical consultations; eliminate the need for repeated blood testing, emergency room visits and hospital admissions, annually.
Another transformative teaching-learning approach, is according to Scharmer (2000), learning from the future as it emerges, which he referred to presencing. The meaning of presencing, Scharmer (2000, p. 4 ) states, is “to sense and bring into the present one’s highest future potential; the future that depends on us to bring it into being”. This type of organisational learning is a change from reflective learning in which learning from past experiences was used. Scharmer (2000) referred to learning through presencing as leaders using their deepened consciousness to sense, represent and enact emerging futures, especially in relational dynamic emerging organisational environments. Thus the leverage point for curricula transformation is the interface between transdisciplinary teams and health professional experts who meet and connect across disciplines and sectors, in which the content of awareness of social actuality and the blind spot or the source from where perception function,; and the systemic collective attention, shifts within the relational structure (Senge et al., 2006). Enacting
curricula reforms in this relational structure between observed or content and observer or Source, is the opening through which the health ecosystem reality comes into being. As explained by Scharmer (2000), our structure of attention characterizes the only part of our social consciousness that we can have complete control of, because we create the structure of attention ourselves; therefore, we understand both the actualized structure of attention and potential alternate ways of operating.
Utilizing these principles of Theory U, as described by Scharmer (2007), in curriculum
reorganisation, facilitates opportunities in which graduating health science students develop holistic insights, for example, the crucial health determinants in the population. Also, through this relational structure of learning they acquire leadership skills to mobilize around leverage points in the system, by increased interdisciplinary and transdisciplinary team practice and learning, social mobilization and political advocacy, irrespective of their area of specialization.
In the dynamic continuously changing health system, continuing education is essential at all levels of the health ecosystem, through interactions in which complexity of health improvement becomes dominant (WHO, 2015). In the Global Strategy on Human Resources for Health: Workforce 2030, the
WHO plans (2015, p.48) emphasise that transformational learning in practice, academic centres and within communities leads to “locally responsive and globally connected health systems leadership”.
In addition core introductory components on the health curricula (Bemporad, 2018) inclusive of integral systems thinking frameworks in the form of E-learning, competency-based health curricula, team-based learning, and engaging in participatory research strengthens trans-professional education in medicine, public health, nursing, allied health and health policy design (Frenk et al., 2010).
Furthermore, integral experiential learning (Pillay, 2014), incorporating academic disciplines such as economics, ecology, anthropology and organisational management, interrupts the traditional
professional and disciplinary silos and reconfigures transdisciplinary relationships, organisational learning and team intelligence, thereby constructing new forms of case studies, practical experiences and systemic collaboration (de Savigny, 2009).
The health science curricula should be integrated with approaches and methods of systems science, for instance, knowledge synthesis, concept mapping, social network analysis, programme budgeting and marginal analysis, and system dynamics modelling, thereby creating opportunities to expand systemic relational learning (Atkinson, 2015). In an article on evolution of perception of self and the world, Pillay (2016) describes that in his experiences of deepening consciousness, the possibility of a period of inner reconfiguration, mental spaciousness, and how seeing the world from a dualistic perspective was an illusion, occurred. From this notion of experiential learning in which deepening one’s consciousness is explored and the courage to empower oneself by deconstructing illusory separation and constructing systems of consciousness, emerges as a possibility to be included on health sciences curricula.
Emergent integral techniques and experiential tools, for example, Theory U, in which shifting the structure of collective attention provides the learning environment for expanding awareness of nondual philosophy, embrace diversity by developing new ways of cooperation and social re- engineering is discovered (Norton, 2012). As a critical mass of individuals reflect on their cognitive limitation and engage in practising this integral consciousness perspective, organisational
consciousness begins to shift and conscious organisations become more aligned with the complexities of the changing external reality, and simultaneously align with emerging possibilities (Reams, 2005).
When health science governance organisations, for example, Health Professional Council of South Africa (HPCSA) in which curricula and policymakers re-examine and question the fundamental assumptions of various theories and practices, and reconceptualise the curriculum by creating meaningful conversations, didactic methodologies and insights of experiential learning, integral consciousness is enabled (Ross, 2012). Adopting this holistic approach to learning provides
opportunities for health science students not only to solve or to interject (Mandala, 2008), but to participate interdependently in interconnected evolutionary holarchy of knowledge and
methodologies, in a process of profound engagement and collective learning (Schieffer, 2016). The concept holarchy has been described by Wilber (2005, p.50) as a hierarchy of holons or subsystems made up of an “arrangement of values” at a number of levels, namely intentional, behavioural, social and cultural values. Individuals identify with each of these values in the holarchy depending on their stage of development. Thus, the integral approach to learning interconnects these subsystems of values and transcends from individual awareness to evolve into collective consciousness.
Moreover, the lens used in integral consciousness occurs at various levels, namely, at the micro-world of individual biosphere, or meso-world in transdisciplinary team learning and the macro-world of the greater collective systemic collaboration. Also, integral consciousness is manifest of the subject- object dialectic relations in the structure of a holon (van Olmen et al., 2012), implying interactions of systems within systems. Holons as defined by Wilber (2007, p.9) are “entities that participate simultaneously in networks of parts and wholes”, as in humans the mental subsystem interacts with the physical subsystem within the whole human system. These integral inquiries to learning transcends, and includes, various theories for example complexity theory and methodologies, by providing insights and opportunities to disclose or integrate patients’ subjective interpretive data, as well as objective behavioural data, intended for diagnosing various health complications, pathologies and systemic imbalances, as well as offering interventional approaches (Artley, 2018).
Furthermore, health systems’ research inevitability requires systems thinking to understand health systems complexities, and enable transformation to become transdisciplinary; using multi-method approaches (Mills, 2011). Systems thinking uses influential methodologies which are under-utilized in transforming health systems research (Homer, 2006). To inform health leaders strategies on
strengthening the relationship between research, policy and practice, implementing complexity theories in qualitative research, and considering the local context, through applying community-based participatory and action research methods, studying organisational networks and understanding the collaborative behaviours that impact health, empirical integral data is generated (Best, 2010).
According to Swanson et al. (2012), rethinking health systems strengthening strategies and qualitative research methodologies will narrow the scientific knowledge translation gap between research and experiential practice. Other benefits of implementing systems thinking qualitative research
methodologies are to consider the diverse health ecosystem contexts, and by mobilizing communities around health promotion, shifts in the research paradigm from the current research-to-practice model to an applied research paradigm (Livingood et al., 2011) emerge. Ethical enactment in health system and policy research is empowered by engaging health policymakers and potential research consumers in research planning, interpretation of findings and to consider implications for intervention; as a
result, significant research outputs as well as potential users’ receptiveness of research findings emerge (Sterman, 2006).
A new leverage for emergence is non-separation and developmental research. The meta- curriculum, with systems thinking that facilitates the interconnectedness of cognitive, emotional and social learning, can be realized (Gilson, 2012). An example of non-separation and developmental research is using the system dynamics modelling approach, which reveals relational feedback loops in dynamic behaviours and health systems activities, thus strengthening understanding of the interconnectedness of cognitive, emotional and social learning (Van Olmen et al., 2012). For instance, evaluation of public health policies (Atun, 2008) and risk assessment, using a system dynamics approach, to evaluate economics of health interventions, and cost-benefit analyses pertaining to competing technologies and healthcare strategies, is another example of engaging transdisciplinary teams in enacting integral ethical research. Also, by embracing an organisational culture that constantly identifies knowledge gaps in health practice procedures and enables integral ethical research to fill these knowledge gaps, iterative holistic learning, a change in thinking and practice behaviours (Lane, 2013) among transdisciplinary teams, emerge.