|Year : 2020 | Volume
| Issue : 3 | Page : 121-128
Exploring fourth-year students' perceptions of the hidden curriculum of a doctor of veterinary medicine program through written reflections
Andrea J Kunze1, Christopher Seals2
1 Department of Educational Psychology, University of Illinois at Urbana-Champaign, Champaign, IL, USA
2 Department of Veterinary Clinical Medicine, University of Illinois at Urbana-Champaign, Champaign, IL, USA
|Date of Submission||25-Jun-2020|
|Date of Acceptance||23-Sep-2020|
|Date of Web Publication||6-Nov-2020|
Ms. Andrea J Kunze
Department of Educational Psychology, University of Illinois at Urbana-Champaign, Champaign, IL
Source of Support: None, Conflict of Interest: None
Introduction: Hidden curriculum (HC) is embedded into interactions and learning opportunities involved with a formal curriculum. The curriculum of US-based Doctor of Veterinary Medicine (DVM) Programs is still understudied. We explored how fourth-year students perceive the HC during their final clinical year in a US-based DVM program. Methods: We used a thematic analysis approach that involved iterative steps of coding and re-coding to explore fourth-year DVM students' perceptions of the HC. We analyzed 182 students' written reflections to a brief reading on HC in veterinary medicine and collected reflections from three cohorts of students during their clinical (4th) year. Results: The three features of the HC (individual development process [IDP], teaching–learning environment [TLE], and communication approaches) were well represented from the coding analysis of fourth-year student reflections. From the three larger features of HC, a total of twenty sub features emerged. The sub features were reported as different frequencies, with the IDP and TLE sub features being reported the most. The different features and sub features of HC are interdependent and further illustrate the complexities of HC. Moreover, findings show that HC is made up of various elements that create a unique HC of DVM programs. Conclusion: Student perceptions of the HC in veterinary settings are diverse and portray many interrelated themes that come together to form a unique HC culture that is supplementary to the formal curriculum of a DVM setting.
Keywords: Clinical education, hidden curriculum, learning environment, social climate, student perceptions, veterinary medical education
|How to cite this article:|
Kunze AJ, Seals C. Exploring fourth-year students' perceptions of the hidden curriculum of a doctor of veterinary medicine program through written reflections. Educ Health Prof 2020;3:121-8
|How to cite this URL:|
Kunze AJ, Seals C. Exploring fourth-year students' perceptions of the hidden curriculum of a doctor of veterinary medicine program through written reflections. Educ Health Prof [serial online] 2020 [cited 2020 Dec 1];3:121-8. Available from: https://www.ehpjournal.com/text.asp?2020/3/3/121/300073
| Introduction|| |
Hidden curriculum (HC) has become a popular phenomenon in education because of its conceptual complexity and attractive terminology. It is often described as implicit or contradicting messages learners receive in verbal (e.g., in conversation) or nonverbal (e.g., watching someone's behaviors) forms from a variety of sources, such as one's instructors or peers. The theoretical framework of HC has emerged from both K-12 education  and medical education. Given that different educational levels and disciplines demand different degrees of autonomy and learning approaches, there is a need to reconsider the framing of HC as discipline specific.
Despite the similarities of medical and veterinary education, there are critical differences in the learning tasks and environments, and communication approaches (CA) utilized. Doctor of Veterinary Medicine (DVM) students are expected to learning basic surgical skills within a 2-week rotation as opposed to medical students whose rotations often last 4–8 weeks. These differences produce environments that are unique to the learning goals of a program, however this raises the question of whether HC should be reframed to fit these spaces. Some researchers have begun to examine HC within 4-year DVM programs; however, most of these studies have relied on frameworks derived from medical education  or focused on a limited number of features of a framework (e.g., identity only ). To address the gap in HC theoretical development from a veterinary medical education perspective, the current study utilized thematic analysis of written reflections to explore how HC is perceived by fourth-year DVM students. In the following section, we briefly describe the makeup of HC as a theoretical framework and its features, and the role of HC in veterinary clinical rotations.
Features of hidden curriculum
Since one of its earliest conceptions, HC researchers have identified social agents and features in their conceptualizations of HC. Three main social agents have been acknowledged, namely teachers, students, and the institution/program. However, most researchers have recognized only one or two agents in previous studies. This study, however, evaluates HC from the lens of students only, but our analysis gives consideration to students' perceptions of all the three main agents. The researchers have also addressed the following three main features in their conceptualizations of HC: individual development processes, teaching/learning environment (TLE), and communication approach. In the sub-sections below, we briefly describe these features, but for a more detailed overview, see Kunze (in prep).
Individual development processes
Of the three features of HC, the individual development process (IDP) has been the most popular feature of HC in past research because of its role in socializing students to the culture of a learning environment or profession., IDP can broadly be defined as the cognitive, behavioral, and affective changes people experience over time, and includes the development of different identities. Within a DVM program, the IDP is shaping students' professionalism, identities as specialists, and their perceptions of social norms in their clinical rotations. For example, students' understanding of empathic client interactions is shaped by their observations of instructors' mannerisms throughout the clinical year (affective change). Differentiating IDP from other features of HC allows for a clearer framework that accounts for the differences in socializations from other curricular features such as pedagogical approaches.
The second-most defining feature of HC would be the TLE in which students' IDPs are developing. TLEs can broadly be defined as the physical/virtual settings with educational goal (s) that span the spectrum of formality (i.e., informal, nonformal, and formal ). A DVM program could have multiple TLEs such as the traditional lecture halls, farm animal fields, and teaching hospitals. Some researchers have argued the goals of education programs (e.g., developing professional doctors) which are filtered through different TLE instructors, and then imposed on the students as they engage with the learning space, thus fostering a HC. For example, two teachers teaching the same course (e.g., animal pathology) but different sections may utilize different teaching practices in their classroom (e.g., lecture vs. hands-on activities), resulting in different learning outcomes or perceptions of the curriculum between the two sections of students. This example also highlights the point that the teaching/learning process is also a communication process, and through the communication choices of the social agents involved in the education program, a HC is either positively or negatively fostered.
The CA, or nature in which the social agents (e.g., student or teacher) deliver or receive information, was more implicitly discussed in the HC literature than IDP or TLE., Different studies have identified various aspects of HC that involve communication, but intentionality and awareness were most commonly discussed., Intentionality is the degree of which a social agent intentionally (or accidentally) shares or receives knowledge, and awareness is how much a social agent is conscious of the information it share or receive. For example, two instructors may have the same goals and intentions of teaching students how to solve a problem but then teach or demonstrate two different methods to the students. Therefore, if students were evaluated only on one method or chastised for not using the “correct” method, it may appear the teaching is contradicting.
Learning theories have made it clear that the HC features of IDP, TLE, and CA have complex, interdependent, and reciprocal relationships with one another (e.g., social cognitive theory); however, the nature of each feature is unique, so researchers should consider the features as exclusive from one another. To date, few studies have considered all the three features of HC within a single study, and many studies have been limited to either K-12 or medical disciplines. Interestingly, even the small number of HC studies that have been conducted in veterinary medicine education settings utilize Hafferty's (1998) medical-based HC framework. In the current study, we used this more comprehensive conceptualization of HC to guide our analyses in better understanding HC from the student perspective within the context of veterinary clinical medicine.
Hidden curriculum in clinical learning spaces
Typically, across the 4-year medical and DVM programs, students begin with didactic lectures and hands-on lab work and progressively work toward more experiential learning through applied hospital work (clinics). The goal behind the formal curriculum is students will develop both content knowledge and lab skills before applying that knowledge to real-world problems, such as a patient diagnosis. Some argue that in medical education settings such as clinics, learning or pedagogy takes a “back seat” to the workload at hand, and thus requires either students to seek out learning opportunities or instructors to embed learning opportunities within the tasks available. Their argument suggests that clinical learning settings (a) have a priority of caseload/patients over students, (b) can be limited in learning opportunities based on cases available, and (c) require effort from students and instructors to optimize learning opportunities. The differences in pedagogical priorities and learning opportunities of clinical settings suggest that we should treat clinical learning environments unique from the first 3 years; however, few to no studies have explored the potential differences in HC experienced by DVM or medical students by year in program or by clinical versus nonclinical settings.
Within their clinical year, DVM students are participating in different clinical rotations every 2 to 4 weeks. In each rotation, students are randomized to a new specialty that provides a different way of thinking about veterinary medicine (i.e., identity development), and they are required to adapt to new peers and new instructors' approaches to teaching and communicating. Each rotation acts as their own microculture, unique yet still a part of the larger 4-year program's culture. Microcultures are defined as groups working together toward some academic endeavor within the same university, department, and program. These microcultural differences can leave room for a diverse HC to emerge within the clinical year as students transition between multiple rotation instructors. In the following sub-sections, we describe in more detail the HC of a DVM program guided by the three HC features: IDP, TLE, and CA.
Individual development processes
Formal curricula and HCs help DVM students develop their identities as professional veterinarians over 4 years, but the final clinical year may offer students the most time to develop applied skills. Regardless of predetermined career plans (i.e., specializing vs. not), all students will be exposed to a variety of specialties for the opportunity to (a) develop professionalism and ethics as future veterinarians and (b) develop as more well-rounded veterinarians. The majority of the studies on HC in veterinary medicine have focused on the former – process of professional and ethical development of DVM students.,,, Researchers have suggested that a HC can be formed around these specialties,, which may be exacerbated in the clinics where each instructor is a specialist who hyper-focuses the rotation tasks to socialize students to their specialty. Our current study does consider how students talk about professionalism and specializations within the clinical setting.
Within the 4th year, DVM students' learning environments are almost exclusively in a hospital or clinical setting where the teaching emphasizes tacit (skills, ideas, or experiences that are not systematic and often hard to put in words) approaches such as modeling and observation. For example, when DVM students are participating in a surgical rotation the learning will involve silently observing an instructor perform surgeries. The instructor performing the surgery may verbalize some of their clinical decisions (e.g., why they use a certain tool); however, much of the instruction or procedure they are modeling will be expected to be tacit. The emphasized use of tacit instruction in clinical spaces creates a unique learning environment, which may invite more opportunities for the HC to function within the curricula. Simply, with less explicit instruction, students will have to rely more on learning through observation which means more opportunities for unintentional misinterpretation or lack of awareness.
Prior literature has highlighted that HC is fostered by a lack of awareness or intention and tacit (nonverbal) communication., In veterinary medicine, some students have perceived some knowledge and practices communicated to them during their first 3 years as contradicting to what is communicated to them in the hospital. For example, students may be taught “best practices” for how to act empathetically toward a client, but during their clinics, they may witness their instructor modeling different behaviors. This example highlights how communication involves the awareness and intentions of students and instructors, and is closely tied with the identity development or socialization of students. The increased opportunity for such miscommunications during clinical rotations raises the need for more studies to critically examine how IDP and TLEs are shaped by the intentions, degrees of awareness, and nonverbal interactions communicated.
There are very few studies in veterinary medicine to date that have explored the concept of HC with a specific focus on the microcultures of clinical rotations. The studies that have explored HC in a veterinary medicine context mostly focus on professionalism and ethical development. Interestingly, CAs have been discussed explicitly the least in the broader HC literature and veterinary medicine (compared to the other two features) despite nonverbal communication being central to the definition of HC. In light of most studies not considering the three major features of HC, our current study attempts to do so within a clinical veterinary medicine environment.
Purpose of study
Although HC research has evolved from K-12 and medical education, researchers have called for more theoretical development and understanding of HC. To define HC clearly within a veterinary medicine, this study utilized a thematic approach  to explore how fourth-year DVM students perceive the HC. We specifically ask how do fourth-year DVM students perceive the HC of their DVM program?
| Methods|| |
Participants and procedures
This mixed-methods study was completed in collaboration with one instructor of a required clinical rotation at one veterinary medical college in the USA. A total of 182 DVM students, across three graduating classes, were asked by the instructor once their 4-week rotation began to read an article on the impacts of HC in veterinary medicine as a part of a voluntary class activity. Demographics were not collected, but approximately 130 students are accepted into each cohort per year. Additionally DVM students are reported to be predominantly White (78%) and female (80%). White.
After reading, students were asked to E-mail a reflection (of any length) on “if you agree with the article and how you perceive the HC at (anonymous institution)” to the clinical rotation instructor. The instructor removed any identifiers from the reflections before sharing the documents with the research team, therefore no consent was required in accordance with our approved human subjects' form (institutional review board #20253).
Students read an article that defined HC and provided negative reports from other institutions about perceptions and experiences with the HC in DVM programs. The text was 2559 words and written for a general veterinary education audience. After reading, students' E-mailed written reflections, which varied in length by student – some wrote a few sentences, while others wrote up to four single-spaced pages.
Our study concurrently uses both qualitative and quantitative approaches because of the large sample size. First, open, axial, and selective coding was used to analyze all student responses. The first author conducted open and axial coding on all the 182 responses, which produced 79 unique and 20 grouped codes, respectively. Example open codes included, “lack of sleep,” “desire for professionalism,” and “difference in clinical styles.” Both stages of coding were discussed with the co-author, and analytic and theoretical memos were written throughout the data analysis process and assisted in the grouping of codes.
The first author then recoded each student's response for the presence (1) or absence (0) of each of the axial codes. Participants had different numbers of codes per response (mean = 5, standard deviation = 2), with the minimum being no codes and the maximum being 16. Although some codes may have appeared more than once in a response, frequency was not considered because our focus was on the presence and not robustness of themes. In addition, a research assistant trained by the first author also coded all the 182 responses for the presence and absence of the axial codes. An overall agreement of 75% was determined, and both coders discussed differences until 100% agreement was achieved for all the 182 responses. Lastly, selective coding was conducted by both authors collaboratively to group the twenty axial codes based on the three features of HC outlined in the literature review: IDP, TLE, and CA.
| Results|| |
Perceived aspects of hidden curriculum
The results suggest that DVM students believe that the negative aspects of the HC are reflected in their DVM program, and these aspects align with the features of IDP, TLE, and CA. The portion (%) of all the 182 students that reported each of the sub features, and an example quote of each, is shown in [Table 1]. The sub-features identified by students aligned with the HC features of IDP (n = 9) and the TLE (n = 9), but the sub-features of CA (n = 2) were perceived the least.
|Table 1: Themes from fourth-year Doctor of Veterinary Medicine students' perceptions of the hidden curriculum of a Doctor of Veterinary Medicine program by hidden curriculum feature|
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Several sub-features did present elements of multiple features (e.g., CA and TLE). However, we categorized the sub-features exclusively to one HC feature based on its most dominant attribute and if the actual text from the participants, which determine the sub-feature (or theme), matched the tone of one HC feature over another.
Individual development process
IDP can be defined as individual schooling experiences that students become socialized to, all of which are HC from the viewpoint of the participant. The nine sub-features identified from most to least reported were well-being, professionalism, specialization bias, empathy, fear of engagement, career relevance, practice preparation, diversity/inclusion, and gender bias. Below, we only discuss the top-reported, however, example quotes of each sub-feature, which are summarized in [Table 1].
Well-being was the most reported IDP sub-feature (47%). Well-being emerged indirectly in many reported quotes about students' eating and sleeping habits. The well-being of the individual student seems to be highly related to the learning environment according to several of the quotes. One student wrote, “There are a handful of professors that truly care about students' well-being and how we are balancing clinical stress (e.g., paperwork, on call time) and trying to have a normal life (e.g., exercise, eating right, and time to one self). As for other faculty, it is the complete opposite story.” This quote brings attention to the unhappiness and inner dissonance that some students are experiencing across the different rotation's microcultures. Earning a DVM is difficult and should be challenging, but some students are concerned about their long-term quality of life, and their ability to balance this lifestyle.
Professionalism touched on how students perceived their clinical instructors' behaviors during interactions with clients and peers, which contradict what they were previously taught. Many students (42%) perceived professionalism as a part of the HC in the clinics. One student that perceived HC around professionalism and empathy shared, “Empathy toward animals is also sometimes lost. I feel like faculty members often think of the animal as a body system and not a living animal with emotions. There needs to be better bedside manners.” Another student stated, “I feel like there are issues with compassion and empathy, especially toward students.” These quotes highlight that the professionalism of a veterinarian is not exclusive from empathic practices, as well as extends to the act of being a respectful and considerate instructor or student.
Specialization bias was a theme that touched on the students' perceived value or usefulness of the content that they learn in the clinics. A related quote shared, “Teaching me should include nurturing an interest…Not everyone wants to specialize in the area that those teaching us are interested in and that's fine. We can't all be specialists. But those that don't want to be shouldn't be thought less of or belittled for wanting to pursue an area that differs from those that are teaching us.” The quote reflects the notion that HC benefits or harms students differently based on their interests and instructor interests. Other biases perceived as HC in the clinics included gender bias and racial bias, and were each reported by 10% of the students. The lack of reports regarding race could be a good sign, but there is still a lot to unpack from the students who did report gender concerns. Regarding race, 10% of all students reported concerns for diversity and inclusion but that 10% can possibly be a much larger portion of the Black, Brown, and minoritized vet student population.
As previously discussed, TLE can be broadly defined as the learning environment that has educational goals. The nine sub-features of TLE from most to least reported include: social climate, ambiguous expectations, evaluation/feedback, instructor motivation, problematic teaching, financial cost, opportunities for involvement, physical resources, and mentorship. Below we only discuss the top-reported, however, example quotes of each sub-feature, which are summarized in [Table 1].
The social climate sub-feature was the most prominent theme found across all the twenty sub-features (56%). Social climate issues related to topics such as negative attitudes and respect, which have an impact on all the three features of HC. One quote that echoed many students' perceptions of the social climate was,
“Students are hearing daily about how 'when I was in vet school we worked 90 h a week,' but just because that is how it was, does not mean that is how it should remain… This cycle just continues to trickle down and those who were treated that way begin treating others that way. We need to implement (more) positive educational opportunities for students so they feel as though their learning is as important as the cases being managed.”
This quote highlights that students perceive some cultural traditions across DVM training as problematic. Some traditions that were mentioned were the normalization and praise of exhaustion/overworking. Such traditions often place the health and wellness of the student as less important, therefore affecting the well-being of the student, as well. Moreover, when this message is communicated (CA), it is often perceived as a contradicting practice. Students are told to take care of themselves by some instructors, but others may require them to work “90 h” in 1 week.
Feelings of ambiguous expectations was also a reported sub-feature (30%). “I have a slight problem with the idea of students being called-in as extra help when there is over flow of work in the intensive care unit or ER… This “on-call” extra help feels a lot more like the school utilizing students as free labor then actually trying to teach us something.” This quote shows that students are unclear about the expectations for their roles as students within certain rotations to the point that they question the relevance of the teaching/learning practices. This is a popular feeling across medical and veterinary education, as priorities shift from teaching to clinical work.
Evaluation and feedback was reported by 29% of students. The quote from [Table 1] represents a frustrated perspective, but highlights the intense and busy environment in which clinics take place, which leads to a TLE that does not always allow time for reflection, feedback, and reviews. One student stated, “I have been on some rotations where they give really helpful constructive written feedback that will allow me to grow as a student and future clinician. However, on most rotations, the clinicians just check a box. I understand they are busy and have a lot of students to grade, but if there are areas where I could improve, I would love those pointed out to me so that I don't continue to make the same mistakes throughout school and worse in practice.” Evaluation and assessment is important for student development as evidenced by the excerpts from this study, but the concerns around evaluation may speak to the stress of the clinicians who don't always have the time to give feedback to several students across a short period of time.
Nearly 40% of the students perceived contradicting practices and 32% perceived organization/accountability as a part of the CA that foster a HC. As previously discussed, CA can be briefly defined as the nature in which agents deliver and receive information. As made apparent in the previous section, contradiction and miscommunication were regularly discussed regarding the TLE, highlighting the complexity and importance of CA in the classroom (or clinic). One student quoted,
“I believe that (there is a) HC whether it is intentional or not. No matter the school or who you work with, there are things you learn from the environment and people at a teaching hospital. For example, when I go into an exam room with a doctor who explains to the client what our plan is going forward with their pet, I pick up on the way they articulate things, their body language, and the way they handle difficult situations. We can be told how to do these things with didactic learning, but it makes more sense when it is witnessed in a real-life situation.”
This quote highlights the role of intentionality in communicating information, as well acknowledges the contradiction or misinterpretations that can arise with the transition from didactic lectures to applied clinical work. Similarly, organization/accountability issues were acknowledged by students as affecting the microcultures of rotations. “The rotations that I have noticed the most conflict are the busiest and more poorly organized. When students are given clear instructions and expectations are clearly defined, things tend to run much more smoothly.” This student acknowledges the positive and negative perceptions of rotations that are fostered partially by the organization and communication system in place between students and instructors.
| Discussion|| |
This study illuminates that DVM students have a wide view of what HC is and what types of learning experiences are not always formally presented to them. HC took on many different characteristics reflected in twenty sub-features that all had an effect on the learning experience of the DVM students. The sub-features that were found all connected to their respective HC feature, but played different types of roles in the relationship between HC and students' learning. For example, some helped create the HC (e.g., physical resources, problematic teaching), whereas others were a result of HC (e.g., fear of engaging, well-being). There were some sub-features that played both roles (e.g., social climate). Irrespective of how we place each sub-feature in relation to it causing or being a result of HC, we cannot ignore the overlap of the sub-features. These overlaps and interconnectedness of the sub-features make up the HC in a DVM program.
The results from our study suggest that despite the negative connotation associated to HC in a DVM setting, it is not perceived as problematic by all DVM students. Specifically, the HC is seen by some students as a part of the learning process experienced during the clinical year that can either hinder or support success. Specifically, one student stated,”
“A HC is unavoidable in my opinion, no matter the profession as humans are humans. The awareness of it is important and setting a good example should absolutely be strived for, but humans are faulty and different. Having a squeaky-clean academic environment is not possible but even if it was it would do more of a disservice to students when they enter the real world. Exposure to different outlooks, approaches, personalities (good and bad), and managing difficulties with others is as important as the medical knowledge.”
This student suggests that the HC should be considered a natural aspect of any curriculum, and that any social agent can play a role in shaping the HC. They note the importance of HC awareness for students, which may help prepare students for unanticipated obstacles.
Furthermore, the results highlighted that students and instructors could benefit from professional development. Specifically, instructors could benefit from learning new veterinary education-specific teaching practices, learning communication styles that are effective under high intense situations (e.g., clinics), and learning how to communicate as educators more effectively, as many veterinarian instructors do not have formal backgrounds in teaching. Students could benefit from learning about HC in their early years of veterinary school to build their awareness. Ultimately, providing both groups of individuals with communication skills could help increase trust and empathy, which is critical for professionalism in health care.
Our study had several limitations. First, the written assignment was voluntary with no word limit which could shape the type of themes and number of themes that emerged from each response. Second, students provided their responses at different time points during their 4th year, meaning some students may have more or less experience in clinical settings to reflect on. Third, our results were limited to the experiences of students at a single institution and are therefore limited in generalizability to other DVM programs. Lastly, HC in the literature and media has a negative connotation which may have primed students to report more negative perceptions.
| Conclusion|| |
Our study revealed the complex and vast understanding that fourth-year DVM students have of HC. HC is not simply defined, and it can also vary depending on the learning context. DVM programs have many unique aspects to the formal curriculum, which contribute to a HC that should be studied and understood within the specific DVM context. We hope our results will help provide insight about the veterinary learning context, teaching practices, and student differences that have varying effects on student success.
The authors were responsible for conceiving and conducting this study, data analysis, and the development of the manuscript. Claims in this study reflect the opinions of the authors and not the university.
The data were anonymized for the purposes of this study (retaining only information about the respondent's semester). The study was approved by the University of Illinois Research Ethics Board.
The authors would like to thank Sylvia Syp for her contributions to the analysis, and the support of Dr. Rick Fredrickson, staff, and the students who made this research possible.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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