What is the hidden curriculum, and how does it affect nursing students?

ABSTRACT: The hidden curriculum can be defined as that which is taught to students unintentionally by the culture, structure, and people of their educational setting. Although most authors agree on its importance, little is written about how the hidden curriculum affects nursing students in both university and clinical placements. The purpose of this review is to take a broad look at the research on the hidden curriculum in an attempt to better understand its current value and future potential, as it affects nursing students and the profession. A brief history of the hidden curriculum is provided in relation to nursing education, followed by a review of the literature with a specific focus on the variety of educational and clinical applications in which it plays important roles. These topics arose from interactions with peers, nurses, non-faculty staff, and other community members, all of which had potential impacts on the students. Ultimately, the hidden curriculum is an understudied, underappreciated component of education, and is one in which students play a major personal role in developing. Both faculty and students need to understand the power and importance of this tool, as it has the capacity to shape the future of the nursing profession.

BACKGROUND:McMaster Professor Geoff Norman, one of the theoretical founders of problem-based learning, recently said, “If you examine student outcomes, 3% of the difference is due to curricula, 7% to teachers, and 90% to students. And that’s in K-12 education; I suspect that curricula play even less of a role in health professions.”1 A longitudinal study in medical education came to the same conclusion: the greatest variability in student outcomes arises from the students, and the least from the curriculum.2 So, if a program’s curriculum matters so little, what is it that differentiates one school’s nursing graduates from another? While the full answers are complex, a notable proportion of the differences may be found not in the stated curriculum, but in the “hidden” curriculum.

The concept of a hidden curriculum is old. The specific term dates back to at least the 1960s and has been applied to healthcare education for several decades thereafter.3 Over the years, four types of curricula have been described:

  1. The formal curriculum:  what the school officially claims to teach in their published course outline or manual.4 
  2. The informal curriculum: the unscripted, or ad hoc, communication between faculty and students, usually in between instances of formal curricula.4 
  3. The null curriculum: the topics or lessons that are “conspicuous by their absence,” such as how a topic deliberately left untouched sends the message that it must be unimportant.5
  4. The hidden curriculum: a combination of factors involving the organization’s structure and culture that affect student learning.4

Overall, the hidden curriculum arises from the culture of the educational setting, the identity of its students, and the informal interactions among peers and non-faculty personnel. As one of the earliest authors in the field of nursing noted, the hidden curriculum is “taught by school, not by any teacher.”6

The hidden curriculum is a fundamental component of what is taught at school, and even as early as 1938, it was recognized that collateral learning was often more important than the intended lesson.7 Indeed, the values and attitudes transmitted through the hidden curriculum appear to have a greater impact on students than the formal curriculum.8 However, it is also a topic filled with controversy among educators. At times, the prevailing wisdom has been to combat the hidden curriculum, at times to ignore it, and at other times to mitigate its presence.4,5,9

REVIEW FINDINGS:In the roughly 40 years since the study of hidden curricula was introduced into nursing literature, there have been few relevant publications. The lack of research is surprising given that until recently, nursing is a field that  has relied primarily on hidden  curricula in the form of peer teaching and on-the-job apprenticeships.10-12 Nursing in Canada only started to become a profession in the 1920s, and the transition into modern theoretical teaching began largely in the 1940s.11 However, even through the 1970s, much of the theoretical curriculum had little transferability into practice and focused instead on rote memorization.13 Student learning was often not the priority for hospitals, and debating their educational needs against the hospitals’ needs remained a persistent theme in every major Canadian nursing report until the 1970s.14 

In the few times when the hidden curriculum was discussed in nursing literature, it traditionally carried a negative connotation, and the discussion focused on mitigating its undesirable outcomes.9,15,16 Indeed, the hidden curriculum has many negative outcomes due to the fact that the surrounding educational culture is difficult to control; however, it would be irresponsible to dismiss it as entirely unwanted for these reasons.4

Lately, literature on hidden curricula have primarily discussed students’ experiences in hospital placements, but there are many other areas within nursing education that involve hidden curricula which deserve our attention.9

HIDDEN CURRICULA WITHIN THE SCHOOL:Just as each university has its own students, staff, history, and culture, so too does each nursing school have its own hidden curriculum.9 And with each hidden curriculum comes a unique set of strengths and challenges that students must face on their path to becoming nurses. 

The concepts of power and privilege in the hidden curricula are addressed by a Canadian article and supported by a study from Iran.9,17 Both pieces highlight how misuse of the staff’s power over students, or treating students differentially, can influence their development into nurses and inadvertently teach them to behave similarly in the future to their patients.9,17 Further qualitative studies from Iran and Pakistan also discuss how unrealistic demands and a lack of resources in their learning environment increased the anxiety and stress of nursing students and contributed to breaches of academic integrity.17,18

On the positive side, the previous Iranian study also highlighted instances where students felt encouraged to act altruistically due to positive interactions with school staff.17 Students also reported that being immersed in a new and challenging environment with different people and cultures helped them develop independence and expand their perspectives as new nurses.17 Another qualitative study from Australia investigated the experiences of peer teachers and learners for simple tasks such as taking vital signs, and found that this near-peer interaction also played a role in professional socialization and camaraderie.16

HIDDEN CURRICULA AT CLINICAL PLACEMENTS:Student nurses spend a large portion of their program in clinical settings, which are perhaps even more important contributors to the hidden curriculum than the classroom. Here, they interact and cooperate with many members of the local community: staff nurses, doctors, clinical managers, allied health professionals, patients, and family members. These interactions with non-faculty individuals are almost always unscripted, making them the ideal avenue for both informal and hidden curricula to predominate. Again, as with any other curriculum, there is considerable potential for both negative and positive influences on students.

One Canadian article discussed an example of hidden curriculum in which nurses have been socialized to wait for physician orders before providing nursing care.19 This practice reduces the quality of patient care and reinforces the idea that nurses are ultimately just following orders.19 In response, students are led to regard nursing as a technical rather than an intellectually stimulating profession.19 The gap between nursing theory and nursing practice is a long-debated topic and is a major focus of research regarding the hidden curriculum in nursing.9,10,15,20 This gap is amplified when the clinical placements’ culture and values misalign with those of the universities, or when there is poor integration between the two entities.10,20 

Although one study from Pakistan reported that the hidden curriculum helped propagate ethical violations, the same study also noted that ethics was rarely taught in nursing school.21 Most of what the nursing students learned about ethics was also via a hidden curriculum.21 Several other international studies supported that hidden curricula not only helped nursing students learn ethics, but helped them build a professional identity by collaborating with staff and other students.17,22-24 

Student nurses have been shown to learn a lot about communication style, attention to patient differences, and ethical considerations of patient teaching through unscripted interactions with patients and other nurses.25 These interactions with other more established nurses were  shown in a New Zealand study to be important components in developing the skills and mechanisms needed to become competent professionals.24

DISCUSSION:It should be noted that most of the research found on hidden curricula was international and multicultural, which may not be generalizable to Canadian nursing. Several sources describe this field as growing, but existing research has only scratched the surface. Areas for suggested research include an increased focus on the impact that hidden curricula have on students’ futures as professionals; whether attempts to harness hidden curricula can be successful; and a better understanding of the importance of contributing factors to hidden curricula. Before conducting investigations, it would be prudent to first develop a better understanding of hidden curricula in Canadian nursing schools. Also, future references to the hidden curriculum should define the term clearly, as the waters are muddy surrounding its relation to the other types of curricula, particularly the informal curriculum. 

In the end, just as any tool, the hidden curriculum can work to the benefit or detriment of a student. It is a culture which is ever-present and ever-changing depending on the people that it involves. It should not be feared, fought against, or ignored. Rather, by understanding what a hidden curriculum entails, teachers and learners can work with it to fulfill their needs.

CONCLUSION:The school one attends and the clinical placements one receives make a difference on learning outcomes, but not entirely for the reason one might expect. Ultimately, it seems that the culture of the learning community has more profound impacts than what is written in the course manual. Culture is both experienced and created: all students add to the culture of their school and placement and, thus, to the hidden curriculum.

As we become senior students, graduate, and go on to become more experienced nurses, we cannot forget that we are always teaching, whether it is formally or in a more “hidden” fashion. We are always influencing those around us and shaping the future of the nursing profession.

ACKNOWLEDGEMENTS: I would like to acknowledge Ruth Chen for first sparking my interest in this subject, Daniel Kim for encouraging me to write this piece, and JoAnn Saldua-Toomath for providing thorough and constructive feedback.

Written by Simon Farquharson

Edited by Daniel Kim

Reviewed by Joann Saldua-Toomath

Graphics by Laura Nguyen

References may be found in Issue 35.

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