Chapter 33
The Hidden Curriculum
Liz Mossop
School of Veterinary Medicine and Science, University of Nottingham, UK
Introduction
The student journey through veterinary education is a process of professional identity formation. As well as developing the knowledge and skills necessary to become effective clinicians, students are learning how to behave as a member of the veterinary profession. While the teaching of professionalism and professional skills should include formal instruction, there is a significant body of evidence indicating that the hidden curriculum will contribute as much, if not more, to the formation of a professional identity. This tacit learning can have either a negative or a positive impact on the professionalism of our students. When designing and implementing veterinary curricula, we must consider the presence of this hidden curriculum, which may be difficult to identify and even more challenging to control.
Table 33.1 A comparison of the formal, informal, and hidden curricula. Note that overlap occurs between these categories, and the terms are often used interchangeably
| Formal curriculum | Informal curriculum | Hidden curriculum |
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What Is the Hidden Curriculum?
The emergence of discussions around the hidden curriculum in clinical education began in the context of teaching medical ethics to trainee doctors. Hafferty and Franks (1994) recognized that while ethical theory and examples of how doctors should behave could be delivered to students in the classroom in a didactic fashion, this may be completely undone by unseen influences in the hospital environment (see Box 33.2). Once students begin interacting with healthcare professionals, their behavior is likely to be significantly influenced by what they see happening around them. Their attitudes are also influenced by the culture of the broader educational environment in which they are trained. The way in which an educational establishment chooses to behave from an ethical perspective leads to tacit learning by students. The hidden curriculum has the potential to undermine even the best teacher of ethics, so when developing a curriculum of ethics and professionalism this should be a key consideration.
Conceptualizing the Hidden Curriculum within Other Curricular Components
While the terms informal and hidden curriculum are sometimes used interchangeably, it is useful to consider them separately despite overlap between the two. This is considered in Table 33.1.
The hidden curriculum is often described in the context of other aspects of the curriculum. Harden (2009) separates the taught, learned, and declared curricula, with some overlap. He places the hidden curriculum over the taught component, showing how this is delivered by teachers. It could be argued that the hidden curriculum actually overlays all aspects of his model, because it is also reflected in the declared curriculum (e.g., through educational policies) and learned curriculum (e.g., through students actively learning from a role model). A further representation of this is in Figure 33.1 and Table 33.2.
Figure 33.1 Four aspects of the curriculum shown diagrammatically to demonstrate the influence of the hidden curriculum (Thistlethwaite and Spenser, 2008; Harden, 2009).
Table 33.2 Conceptualization of different aspects of the curriculum
| Intended curriculum | Delivered curriculum | Assessed curriculum | Received curriculum |
| Formal teaching and learning as described in course documentation. | What is actually delivered “on the day.” | Aspects of teaching and learning that are included in examinations. | What students take away from a teaching event. This includes the hidden curriculum. |
Source: Thistlethwaite and Spencer, 2008.
The hidden curriculum is therefore an important consideration for anyone engaging in educational design, particularly when developing a curriculum of professionalism. If sufficient attention is not paid to the hidden curriculum, then the best-intentioned teaching on professionalism is likely to fail.
Development of Ideas about the Hidden Curriculum in Clinical Education
The hidden curriculum was first identified as an important aspect of learning by Jackson (1953), who described the issue in the context of educating children. He recognized that as well as learning knowledge and skills, children went through a process of socialization that strongly influenced their behavior. In other words, they learn their three Rs of “rules, regulation, and routines” as well as reading, writing, and arithmetic. This socialization process is an essential part of a child’s development, and the challenge for teachers is ensuring that the outcome is a child who knows how to behave appropriately. This can be difficult, especially when implicit learning conflicts with explicit rules laid out by teachers. The resulting effect can be very challenging to control, as socialization is often a very powerful force in learning.
The classic sociological text Boys in White described the hidden curriculum through an ethnographic study of students training in a US medical school during the 1950s (Becker et al., 1961). Much of what was being learned during training was not formally delivered, and these influences were negative as well as positive, shaping the attitudes and behaviors of these future doctors. While the curriculum was attempting formally to encourage proper consideration of ethical dilemmas, the institutional environment and behavior of senior physicians around the students directly conflicted with this learning.
Subsequently there has been a huge amount of publication and discussion around the challenges of the hidden curriculum in medical education. Although there has been less in the context of veterinary education specifically, it is clear that it is no less important in this context, and potentially more so (Whitcomb, 2014). Veterinary practice is often described as a “moral maze,” with ethical conflicts regularly occurring in the workplace (Batchelor and McKeegan, 2012). If there is a wish for veterinary students to be able to manage these dilemmas, it is extremely important to consider the hidden curriculum, which will influence their moral development as they learn to become professionals (see Box 33.3).
Situated Learning
When discussing the concept of the hidden curriculum, in effect what we mean is the culture of the environment in which students are learning, and how this may influence their future practice. A useful way to frame this is by consideration of situated learning theory (Lave and Wenger, 1991), which describes how students learn via “legitimate peripheral participation” in a community of practice such as a hospital. They are learning the “rules of the game” in order that they might fit in seamlessly with the type of behavior happening around them, and be entrusted to carry out tasks. Veterinary students are likely to have to engage with a range of different learning environments, both clinical and nonclinical, encouraging them to, potentially unwittingly, adapt their behaviors accordingly. This may not be a good thing, as the students struggle to establish which of these behaviours is correct. Conflict and stress could be the outcome, leaving educators within the formal curriculum to resolve these difficulties.
The Hidden Curriculum in Workplace Learning
While the hidden curriculum is important in all aspects of veterinary education, veterinary clinics are likely to be the predominant influence on the development of professionalism in students, especially as exposure occurs mostly toward the end of training. The veterinary workplace is a busy, stressful environment, where people make quick decisions and are put under constant pressure to respond to demands from clients and coworkers. Behavior therefore may not always reflect values, and so has the potential to be negative. Resources may also be stretched, or unevenly distributed, and activity like this can further influence the hidden curriculum. It is therefore of particular importance to consider how veterinary students learn in the clinic in order to consider the hidden curriculum and address any issues that it may raise (Scholz, Trede, and Raidal, 2013).
Elements of the Hidden Curriculum
Although it is difficult to define exactly what makes up the hidden curriculum, certain components are frequently considered, particularly when designing a curriculum in its broadest sense. In many ways, the hidden curriculum is the equivalent of an organization’s culture, so the model from Johnson (1987) is a useful way to consider its constituent components. This is demonstrated in Figure 33.2.
Figure 33.2 The cultural web, a useful way of considering different influential aspects of the educational environment. Source: Johnson, 1987.
Role Models
Most veterinary professionals can look back through their career and identify someone who has influenced their choices. Whether this is a charismatic and high-achieving surgeon, or an altruistic shelter veterinarian, their influence may be strong (see Box 33.4). While it may be more challenging to identify someone who has influenced an individual’s attitudes to particular situations, learning theories tell us that this is almost certainly the case (Lave and Wenger, 1991; Bandura, 1986). As novices develop into experts, they will subconsciously reflect on the attitudes and behaviors of those around them and are very likely to follow their lead, whether their role model is behaving appropriately or not. Positive role models are likely to demonstrate excellence in clinical competence, teaching ability, and their personal attributes (Passi et al., 2013). Negative role models can be failing in one or all of these areas, and are unlikely to recognize the impact that this may have on student development.
The impact of role modeling is therefore clear in many situations. For example, if a resident is judgmental about a certain client who cannot afford to pay for the veterinary treatment offered to them, students may behave this way the next time they see such a client. In contrast, if the resident demonstrates empathy and acts altruistically toward this client, students may be influenced to behave in this more positive fashion in the future. Role models also have the ability to undermine the efforts of the formal curriculum. A good example of this is in the teaching of communication skills. Veterinary students may be taught to use the Calgary–Cambridge model of the consultation (Radford et al., 2006), and practice this in role plays with simulated clients. If they then enter the clinical environment and this model is not being implemented, they are likely tacitly to reject this teaching and role model the approach of the clinician they are observing. While this may not necessarily be a poor communication style, it is not helpful for previous teaching that is aimed at novice communicators to be “undone” in this way. Role models therefore influence students not only in career choice, but also in professional behavior and the formation of their professional identity (Passi and Johnson, 2016).
The Role-Modeling Process
While learning theories such as situated learning and social learning help us consider the process of learning from a role model, it is interesting to break down what actually happens during the identification of a role model in order to implement this more formally within the veterinary curriculum. A qualitative study of medical students and senior physicians identified both conscious and subconscious elements to role modeling (Passi and Johnson, 2016). The role-modeling process consists of an exposure phase, where attributes such as communication skills and personality are demonstrated by role models; and an evolution phase, where students observe these behaviors and make a judgment as to whether to engage in them themselves. A model-trialing cycle results, where students experiment with what they have seen and adapt it for their own behavior and attitudes.
Role Modeling and Veterinary Teachers
The daily interactions between veterinary clinicians and veterinary students in the workplace make role modeling an important consideration. Teaching by humiliation and making learners feel embarrassment if they cannot answer questions or perform certain tasks may lead veterinary students to behave in the same way when they become the teacher. If teachers can be encouraged to reflect on their influential position as a role model, then their own teaching skills are likely to improve (Burgess, Oates, and Goulston, 2016). Teacher training is a good way of ensuring that this occurs formally, and veterinary clinicians should be encouraged to engage in programs where reflection is fostered and assessed. Teaching portfolios are an excellent way of helping with this (de Rijdt et al., 2006), and by formally reflecting on their own practice, teachers will prompt students to do the same.
Peer-to-Peer Role Modeling
Role modeling also occurs on a peer-to-peer basis, with students learning about appropriate behavior from each other. If a certain veterinary student is consistently late and rude to teachers, other students may tacitly learn that this is normal behavior, and copy it themselves. It is therefore important that such behavior is not seen to be condoned. The monitoring of this type of low-level unprofessionalism can be brought into the formal curriculum through systems such as the conscientiousness index (McLachlan, Finn, and MacNaughton, 2009), where students are rated consistently on objectively measurable aspects of their behavior such as timekeeping and communication. Peer mentoring systems are an excellent method of helping students to demonstrate high standards of professional behavior and to encourage peers to do the same.
Moving Role Modeling into the Formal Curriculum
Role modeling has huge potential to have a strong positive influence on students if veterinary educators encourage the concept in a more formal way (Kenny, Mann, and MacLeod, 2003), moving it from the hidden to the informal or formal curriculum. Students can be asked to identify aspects of behavior in the clinicians around them and reflect on both positive and negative attributes. They can also be required within the formal curriculum to identify an individual as a role model and approach them to be a mentor. The mentor–mentee relationship should include discussion about career path, but should also encourage reflection on difficult situations that the student may have experienced.
Institutional Policies
Formal regulations laid out by a veterinary education establishment can unwittingly influence students through the hidden curriculum. While there are many unseen rules to navigate, faculty should seek to ensure that more explicit documents such as codes of conduct and assessment regulations are fair and transparent. If this is not the case, then students could learn to resist authority, which may not be a good thing.
A pertinent example of this is the use of animals in research and teaching by veterinary schools. It is extremely important that students can see that the decision to use animals in this way has been through a robust and transparent ethical review process. If this has not occurred, and students perceive the use of animals as unnecessary, then they may rebel against the school’s authority and lose respect for the leadership. Although this may be necessary to incite change, if the school behaves unethically and students see this as normal, they may do the same in their future career, jeopardizing their position as a veterinarian. A further example of the necessary questioning of authority is in the context of patient safety (Leonard, Graham, and Bonacum, 2004). If the hierarchy is such in a clinical team that a student feels they cannot speak out when they witness an error, this may have a negative impact on animal welfare. The culture of a clinical environment should therefore be conducive to allowing this, which should be reflected in formal rules and regulations.
Language
The “institutional slang” that permeates throughout veterinary schools is considered to be part of the hidden curriculum (Hafferty, 1998). There is certainly a strong inclination for schools to develop their own language, which is often full of acronyms and abbreviations. The same is true of the clinical environment, which can be completely foreign to an outsider such as a new student beginning a clinical placement. The process of learning this language becomes part of the enculturation into this environment, and this can be challenging if no assistance is forthcoming. The tone of this language is also influential: there has been a concern that the marketization of higher education has led to increasing use of business language among faculty, which may deliver the wrong message to students. If students become very consumerist, then they may approach learning in a surface way, and fail to view their education as the partnership it should be (Kahu, 2013). This is concerning, because it could influence students in a nonhumanistic manner (Hafferty, 1998). While students need to learn about the business aspects of veterinary practice, there is an argument that this should be done through the formal curriculum so that negative tacit learning is prevented.
Equally, the overall tone of language can potentially influence student professionalism negatively if challenging issues are made light of. A culture of “gallows humor” – derogatory or cynical language, often seen as a coping mechanism for the management of ongoing interaction with death and the dying – can have a strong negative impact on developing professionals (Piemonte, 2015). It is important to ensure that students can recognize when this type of language may or may not be appropriate, and that it does not cause harm by being misinterpreted (Wear et al., 2009).
Resources
Veterinary schools have to make daily decisions about the allocation of resources. In addition, they may attract sponsors who have a specific stance on a certain ethical issue. Actions taken in this respect will contribute to the hidden curriculum, and care must be taken that this does not influence students in a negative way. For example, a drug company may sponsor a seminar or gift for clinicians. A process should be in place to ensure that such things are declared properly, so that conflicts of interest do not arise (Katz, Caplan, and Merz, 2010). Schools should allocate resources fairly and transparently, so that students do not perceive unfairness and normalize this as a behavior seen in an environment they trust.
Rituals
The importance of professionalism-related rituals such as “white coat ceremonies” has been widely described in medical education (Wear, 1998; Huber, 2003). These events put the focus on the transition to becoming a professional and encourage students to focus on attributes of professionalism, through both the informal and hidden curricula. However, there are other rituals that occur throughout veterinary school that form part of the hidden curriculum. Social and sporting events involving students and faculty are an important aspect of this. Faculty must be aware that even in this environment their behavior may be role modeled by students, so professionalism must be maintained. Equally, attitudes regarding an appropriate work–life balance can also be demonstrated by engaging in out-of-school social events with students.
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